Crash of Pinnacle Airlines Flight 3701 Bombardier CL-600 ...libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR07-01.pdf · Crash of Pinnacle Airlines Flight

aviation

Crash of Pinnacle Airlines Flight 3701Bombardier CL-600-2B19, N8396A

Jefferson City, MissouriOctober 14, 2004

ACCIDENT REPORTNTSB/AAR-07/01

PB2007-910402

Aircraft Accident Report

Crash of Pinnacle Airlines Flight 3701Bombardier CL-600-2B19, N8396AJefferson City, MissouriOctober 14, 2004

NTSB/AAR-07/01PB2007-910402 National Transportation Safety BoardNotation 7695E 490 L’Enfant Plaza, S.W.Adopted January 9, 2007 Washington, D.C. 20594

E PLUR IBUS UNUM

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NAL TRA S PORTA

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B OARDSAFE T Y

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National Transportation Safety Board. 2007. Crash of Pinnacle Airlines Flight 3701, BombardierCL-600-2B19, N8396A, Jefferson City, Missouri, October 14, 2004. Aircraft Accident ReportNTSB/AAR-07/01. Washington, DC.

Abstract: This report explains the accident involving a Bombardier CL-600-2B19, N8396A, whichcrashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport, JeffersonCity, Missouri. During the flight, both engines flamed out after a pilot-induced aerodynamic stalland were unable to be restarted. Safety issues discussed in this report focus on flight crew trainingin the areas of high altitude climbs, stall recognition and recovery, and double engine failures;flight crew professionalism; and the quality of some parameters recorded by flight data recorderson regional jet airplanes.

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation, railroad, highway, marine,pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by Congress through the Independent Safety BoardAct of 1974 to investigate transportation accidents, determine the probable causes of the accidents, issue safety recommendations, studytransportation safety issues, and evaluate the safety effectiveness of government agencies involved in transportation. The Safety Boardmakes public its actions and decisions through accident reports, safety studies, special investigation reports, safety recommendations, andstatistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about available publications alsomay be obtained from the Web site or by contacting:

National Transportation Safety BoardPublic Inquiries Section, RE-51490 L’Enfant Plaza, S.W.Washington, D.C. 20594(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical Information Service. Topurchase this publication, order report number PB2007-910402 from:

National Technical Information Service5285 Port Royal RoadSpringfield, Virginia 22161(800) 553-6847 or (703) 605-6000

The Independent Safety Board Act, as codified at 49 U.S.C. Section 1154(b), precludes the admission into evidence or use of Board reportsrelated to an incident or accident in a civil action for damages resulting from a matter mentioned in the report.

iii Aircraft Accident Report

Contents

Figures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x

1. Factual Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.1 History of Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11.2 Injuries to Persons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.3 Damage to Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61.4 Other Damage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.5 Personnel Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

1.5.1 The Captain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71.5.1.1 Pilot and Simulator Instructor Interviews Regarding the Captain . . . . . . . . . . . . 8

1.5.2 The First Officer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91.5.2.1 Pilot and Simulator Instructor Interviews Regarding the First Officer . . . . . . . . 10

1.6 Airplane Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101.6.1 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.6.2 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.6.3 Maintenance Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

1.7 Meteorological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.8 Aids to Navigation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.9 Communications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.10 Airport Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

1.10.1 Air Traffic Control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.11 Flight Recorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

1.11.1 Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161.11.2 Flight Data Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

1.12 Wreckage and Impact Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171.12.1 Powerplants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181.12.2 Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

1.13 Medical and Pathological Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.14 Fire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.15 Survival Aspects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.16 Tests and Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

1.16.1 Aircraft Performance Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.16.1.1 Climb to 41,000 Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.16.1.2 Aerodynamic Stall and Upset Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211.16.1.3 Descent and Glide Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

1.16.2 Cockpit Voice Recorder Studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 241.16.3 Engine Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261.16.4 Load Control Valve Simulation Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

1.17 Organizational and Management Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281.17.1 Ground School and Simulator Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

iv Aircraft Accident ReportContents

1.17.1.1 Upset Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281.17.1.2 High Altitude Climbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 291.17.1.3 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301.17.1.4 Stall Recognition and Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 301.17.1.5 Crew Resource Management Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311.17.1.6 Leadership Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

1.17.2 Flight Manuals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321.17.2.1 High Altitude Climbs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 321.17.2.2 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331.17.2.3 Stall Protection System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351.17.2.4 Flight Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

1.17.3 Federal Aviation Administration Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351.18 Additional Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

1.18.1 Oxygen Mask Use During the Accident Flight . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361.18.2 Core Lock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361.18.3 Previous Related Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

1.18.3.1 Core Lock . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 381.18.3.2 Crew Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391.18.3.3 Flight Data Recorder Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

1.18.4 Federal Aviation Administration Notice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411.18.5 Bombardier All Operator Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

2. Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442.1 General . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442.2 Accident Sequence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

2.2.1 Climb to 41,000 Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 442.2.2 Aerodynamic Stall and Upset Event . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 462.2.3 Double Engine Failure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

2.2.3.1 Performance of the Double Engine Failure Checklist . . . . . . . . . . . . . . . . . . . . 502.2.4 Communications With Air Traffic Controllers

and Management of Forced Landing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 522.2.5 Accident Sequence Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

2.3 Flight Crew Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 552.3.1 High Altitude Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 552.3.2 Stall Recognition and Recovery Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 562.3.3 Double Engine Failure Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

2.4 Flight Crew Professionalism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582.4.1 Part 91 Operations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 582.4.2 Industrywide Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60

2.4.2.1 Pilot Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 612.4.2.2 Operator Responsibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

2.5 Quality of Flight Data Recorder Data for Regional Jet Airplanes . . . . . . . . . . . . . . . . . 68

3. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703.1 Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 703.2 Probable Cause . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73

v Aircraft Accident ReportContents

4. Safety Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 744.1 New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 744.2 Previously Issued Recommendation Reiterated and Classified in This Report . . . . . . . 754.3 Previously Issued Recommendations Resulting From This Accident Investigation . . . 76

5. Appendixes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79A: Investigation and Hearing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79B: Cockpit Voice Recorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80C: Pinnacle Airlines’ Double Engine Failure Checklist

at the Time of the Accident. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143D: Pinnacle Airlines’ Revised Double Engine Failure Checklist . . . . . . . . . . . . . . . . . . . 149E: Core Lock Safety Recommendation Letter. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154

vi Aircraft Accident Report

Figures

1. Components in the CRJ Pneumatic Supply and Start Systems . . . . . . . . . . . . . . . . . . . . . . 12

2. Glide Distances for the Accident Airplane . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

vii Aircraft Accident Report

Abbreviations

a.c. alternating current

AC advisory circular

AD airworthiness directive

ADG air-driven generator

AIRMET airman’s meteorological information

AIZ Lee C. Fine Memorial Airport, Kaiser Lake Ozark, Missouri

ALPA Air Line Pilots Association

AND airplane nose down

ANU airplane nose up

AOA angle of attack

APU auxiliary power unit

ARTCC air route traffic control center

ASAP Aviation Safety Action Program

ASOS automated surface observing system

ATC air traffic control

ATOS Air Transportation Oversight System

ATS air turbine starter

CFR Code of Federal Regulations

cg center of gravity

CRJ Canadair regional jet

CRM crew resource management

CVR cockpit voice recorder

DTW Detroit Metropolitan Wayne County Airport, Detroit, Michigan

EICAS engine indicating and crew alerting system

FAA Federal Aviation Administration

FCOM flight crew operating manual

Abbreviations viii Aircraft Accident Report

FDR flight data recorder

FMS flight management system

FOQA flight operational quality assurance

fpm feet per minute

FSDO flight standards district office

GAO Government Accountability Office

GE General Electric

GPWS ground proximity warning system

Hg mercury

ICAO International Civil Aviation Organization

ILS instrument landing system

ISA International Standard Atmosphere

JEF Jefferson City Memorial Airport, Jefferson City, Missouri

KIAS knots indicated airspeed

LBO Floyd W. Jones Lebanon Airport, Lebanon, Missouri

LCV load control valve

LIT Little Rock National Airport, Little Rock, Arkansas

LOSA Line Operations Safety Audit

METAR meteorological aerodrome report

msl mean sea level

MSP Minneapolis-St. Paul International Airport, Minneapolis, Minnesota

N1 engine fan speed

N2 engine core speed

NWS National Weather Service

POI principal operations inspector

SB service bulletin

SGF Springfield-Branson Regional Airport, Springfield, Missouri

SMS safety management system

S/N serial number

Abbreviations ix Aircraft Accident Report

SPS stall protection system

TBN Waynesville Regional Airport, Fort Leonard Wood, Missouri

VIH Rolla National Airport, Rolla/Vichy, Missouri

x Aircraft Accident Report

Executive Summary

On October 14, 2004, about 2215:06 central daylight time, Pinnacle Airlinesflight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19, N8396A,crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport,Jefferson City, Missouri. The airplane was on a repositioning flight from Little RockNational Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International Airport,Minneapolis, Minnesota. During the flight, both engines flamed out after a pilot-inducedaerodynamic stall and were unable to be restarted. The captain and the first officer werekilled, and the airplane was destroyed. No one on the ground was injured. The flight wasoperating under the provisions of 14 Code of Federal Regulations Part 91 on aninstrument flight rules flight plan. Visual meteorological conditions prevailed at the timeof the accident.

The National Transportation Safety Board determines that the probable causes ofthis accident were (1) the pilots’ unprofessional behavior, deviation from standardoperating procedures, and poor airmanship, which resulted in an in-flight emergency fromwhich they were unable to recover, in part because of the pilots’ inadequate training;(2) the pilots’ failure to prepare for an emergency landing in a timely manner, includingcommunicating with air traffic controllers immediately after the emergency about the lossof both engines and the availability of landing sites; and (3) the pilots’ impropermanagement of the double engine failure checklist, which allowed the engine cores to stoprotating and resulted in the core lock engine condition. Contributing to this accident were(1) the core lock engine condition, which prevented at least one engine from beingrestarted, and (2) the airplane flight manuals that did not communicate to pilots theimportance of maintaining a minimum airspeed to keep the engine cores rotating.

The safety issues discussed in this report focus on flight crew training in the areasof high altitude climbs, stall recognition and recovery, and double engine failures; flightcrew professionalism; and the quality of some parameters recorded by flight datarecorders on regional jet airplanes. Safety recommendations concerning these issues areaddressed to the Federal Aviation Administration.

1 Aircraft Accident Report

1. Factual Information

1.1 History of FlightOn October 14, 2004, about 2215:06 central daylight time,1 Pinnacle Airlines

flight 3701 (doing business as Northwest Airlink), a Bombardier CL-600-2B19,2 N8396A,crashed into a residential area about 2.5 miles south of Jefferson City Memorial Airport(JEF), Jefferson City, Missouri. The airplane was on a repositioning flight3 from LittleRock National Airport (LIT), Little Rock, Arkansas, to Minneapolis-St. Paul InternationalAirport (MSP), Minneapolis, Minnesota. During the flight, both engines flamed out4 aftera pilot-induced aerodynamic stall and were unable to be restarted. The captain and the firstofficer were killed, and the airplane was destroyed. No one on the ground was injured. Theflight was operating under the provisions of 14 Code of Federal Regulations (CFR)Part 91 on an instrument flight rules flight plan. Visual meteorological conditionsprevailed at the time of the accident.

Flight 3701 departed LIT about 2121. The flight plan indicated that thecompany-planned cruise altitude was 33,000 feet. About 5 seconds after takeoff, when theairplane was at an altitude of about 450 feet mean sea level (msl)5 (about 190 feet aboveground level), the first of three separate pitch-up maneuvers during the ascent occurredwhen the flight crew moved the control column to 8º airplane nose up (ANU), causing theairplane’s pitch angle to increase to 22º and resulting in a vertical load of 1.8 Gs.6 The rateof climb during this pitch-up maneuver was 3,000 feet per minute (fpm). Immediatelyafterward, the flight data recorder (FDR) recorded stickshaker and stickpusheractivations,7 a full airplane-nose-down (AND) control column deflection, a decrease inpitch angle, and a drop in vertical load to 0.6 G.

About 2125:55, when the airplane was at an altitude of about 14,000 feet, the flightcrew engaged the autopilot. The air traffic control (ATC) transcript and FDR data showed

1 All times in this report are central daylight time based on a 24-hour clock.2 The accident airplane was a Canadair regional jet (CRJ) -200 model, which is one of three models in

the CL-600-2B19 series. (The other two models are the CRJ-100 and CRJ-440.) Bombardier acquiredCanadair in December 1986.

3 A repositioning flight relocates an airplane to the airport where the airplane’s next flight is scheduled.Repositioning flights do not carry revenue passengers or cargo but can carry nonrevenue passengers.

4 A flameout is an interruption of a turbine engine’s combustion process that results in anuncommanded engine shutdown.

5 All altitudes and elevations in this report are msl unless otherwise noted.6 G is a unit of measurement that is equivalent to the acceleration caused by the earth’s gravity

(32.174 feet/second2).7 The stickshaker produces vibrations in the control columns to warn pilots of an impending stall. If

the angle of attack (AOA) continues to increase, the stickpusher moves the control columns forward (nosedown) automatically to prevent an aerodynamic stall, which can occur afterward.

Factual Information 2 Aircraft Accident Report

that the flight crewmembers changed seats in the cockpit during this time,8 but the ATCtranscript did not indicate the reason for the seat change. About 2127:15, when theairplane was at an altitude of about 15,000 feet, the flight crew disengaged the autopilot.

About 2127:17, when the airplane was in level flight at an altitude of 15,000 feet,the second pitch-up maneuver began when the flight crew moved the control column to3.8º ANU, causing the airplane’s pitch angle to increase to 17º and resulting in a verticalload of 2.3 Gs. The rate of climb during this pitch-up maneuver reached 10,000 fpmbriefly. Between about 2128:40 and about 2128:43, the flight crew made a left rudderinput of 4.2º, a right rudder input of 6.0º, and a left rudder input of 0.4º, resulting in lateralloads of -0.16 G, 0.34 G, and -0.18 G, respectively. About 17 seconds later, the flight crewmade a right rudder input of 7.7º. About 2132:40, when the airplane was in level flight atan altitude of 24,600 feet, the third pitch-up maneuver began when the flight crew movedthe control column to 4º ANU, which increased the airplane’s pitch angle to more than 10ºand resulted in a vertical load of 1.87 Gs.9 The rate of climb during this pitch-up maneuverreached 9,000 fpm briefly.

The ATC transcript showed that the captain requested a climb to 41,000 feet,which is the Canadair regional jet (CRJ) maximum operating altitude,10 about 2135:3611

and received clearance to climb to that altitude about 2136:13.12 The cockpit voicerecorder (CVR) recording began about 2144:44 with the captain and the first officerdiscussing the climb to 41,000 feet. About 2148:44, the first officer stated, “man we cando it. Forty one it.” About 2151:51, the first officer stated, “there’s four one oh my man.”About 2152:04, the CVR recorded the first officer laughing as he stated, “this is … great.”FDR data showed that, about 2152:08, the airplane was in level flight at 41,000 feet. FDRdata also showed that the airplane climbed from 37,000 to 41,000 feet at an airspeed thatdecreased from 203 knots/0.63 Mach13 at the start of the climb to 163 knots/0.57 Mach asthe airplane leveled off.14 The FDR data further showed that the autopilot vertical speed

8 The cockpit voice recorder (CVR) did not preserve any information or sounds associated with theseat change because the CVR had the capability to record only the final 30 minutes of the flight. Forinformation about the seat change, see section 1.16.2.

9 According to the ATC transcript, the controllers made no transmissions to the pilots that requiredthem to perform the three pitch-up maneuvers during the ascent. For more information about the threepitch-up maneuvers, see section 1.16.1.1.

10 The maximum operating altitude of the CRJ-200 is the maximum density altitude at which theairplane is certified to operate. For the CRJ-200, the maximum operating altitude of 41,000 feet representsthe maximum capability of the airplane; the actual altitude capability will primarily depend on airspeed,weight, and ambient temperature.

11 The airplane was at an altitude of about 32,000 feet at the time.12 During postaccident interviews, Pinnacle Airlines pilots stated that some pilots had expressed

curiosity about operating the airplane at 41,000 feet and that an informal “[flight level] 410 club” existed atthe airline. Managers at Pinnacle Airlines, including the chief pilot, the CRJ program manager, and the vicepresident of safety and regulatory compliance, were not aware of the club’s existence.

13 Mach is a number that expresses the ratio of the speed of an object to the speed of sound in thesurrounding medium. The Safety Board calculated Mach number using the computed airspeed and total airtemperature recorded on the FDR.

14 All airspeeds cited in this report are knots indicated airspeed unless noted otherwise.


mode was engaged during the climb with a commanded vertical speed of 500 fpm and thatthe airplane’s angle of attack (AOA) at 41,000 feet was initially 5.7º.

About 2152:22, the CVR recorded the captain asking the first officer whether hewanted something to drink and then the first officer responding that he wanted a soda.CVR evidence indicated that the captain left his seat shortly afterward to get the drink.

About 2153:28, the CVR recorded the captain stating, “look how high we are.”About 2153:42, a controller at the Kansas City Air Route Traffic Control Center (ARTCC)asked the pilots whether they were flying a CRJ-200. The captain confirmed thisinformation, and the controller stated, “I’ve never seen you guys up at forty one there.”About 2153:51, the captain replied, “we don’t have any passengers on board so wedecided to have a little fun and come on up here.” About 2153:59, the captain added, “thisis actually our service ceiling.”15

About 2154:07, the captain told the first officer, “we’re losing here. We’re gonnabe … coming down in a second here.” About 3 seconds later, the captain stated, “this thingain’t gonna … hold altitude. Is it?” The first officer responded, “it can’t man. We …(cruised/greased) up here but it won’t stay.” About 2154:19, the captain stated, “yeahthat’s funny we got up here it won’t stay up here.”

About 2154:32, the captain contacted the controller and stated, “it looks like we’renot even going to be able to stay up here … look for maybe … three nine oh or threeseven.”16 About 2154:36, the FDR recorded the activation of the stickshaker.17 FDR datashowed that, at that point, the airplane’s airspeed had decreased to 150 knots, and its AOAwas about 7.5º.

The FDR recorded activations of the stickshaker and the stickpusher18 three timesbetween 2154:45 and 2154:54.19 FDR data showed that, after the second activation of thestickshaker and stickpusher, the No. 1 (left) and No. 2 (right) engines’ N1 (fan speed) andfuel flow indications began decreasing. FDR data also showed that, at the time of thesecond stickpusher activation, the airplane’s AOA had increased to 12º and that, after thestickpusher activated for the third time, the pitch angle decreased from 7º to -20º.

15 The service ceiling is the altitude at which the best rate of climb airspeed will produce a 100-fpmclimb. The service ceiling varies depending on airspeed, weight, and ambient temperature. The accidentairplane was not at maximum weight and was capable of climbing at a rate greater than 100 fpm while at analtitude of 41,000 feet if the airspeed had been maintained at Mach 0.7.

16 The ATC transcript showed that, after this request, the controller began coordinating the descent.17 For the Mach number at this time, the CRJ-200 stickshaker AOA is about 7.8º at the time of shaker

activation. The stickshaker activates at an airspeed of about 150 knots. 18 For the Mach number at this time, the CRJ-200 stickpusher AOA is about 10.5º at the time of pusher

activation. The stickpusher activates at an airspeed of about 142 knots.19 For more information about the stickshaker and stickpusher activations, see section 1.16.1.2.


About 2154:57, the FDR recorded the fifth activation of the stickshaker and thefourth activation of the stickpusher. Even with the stickpusher’s activation, the motion ofthe airplane continued to increase its AOA to the maximum measurable value of 27º.20

The pitch angle increased to 29º, and the airplane entered an aerodynamic stall. Afterward,a left rolling motion began, which eventually reached 82º left wing down, the airplane’spitch angle decreased to -32º, and both engines flamed out. About 2155:06, the captainstated to the controller, “declaring emergency. Stand by.” FDR data showed that, duringthe next 14 seconds, the flight crew made several control column, control wheel, andrudder inputs and recovered the airplane from the upset at an altitude of 34,000 feet.During the recovery, the CVR recorded a sound similar to decreasing engine rpm, andFDR data showed that the No. 1 and No. 2 engines’ N1 indications continued to decreaseand that the engines’ fuel flow indications were at zero.21

About 2155:14, the controller told the pilots to descend and maintain an altitude of24,000 feet; about 5 seconds later, the captain acknowledged the assigned altitude. About2155:20, the FDR stopped recording because normal a.c. power to the airplane was lost.(The CVR had a different source of power and continued to record.) The last reliable N2(core speed) recorded by the FDR before it stopped operating was 46 percent for the No. 1engine and 51 percent for the No. 2 engine.

About 2155:23, one pilot stated to the other, “we don’t have any engines,” and,about 10 seconds later, the captain stated, “double engine failure.” About 2156:42, theflight crew began performing the double engine failure checklist,22 which required pilotsto maintain 240 knots until they were ready to initiate the double engine failureprocedure.23 The checklist indicated that, if the airplane were at or below 21,000 feet andabove 13,000 feet, pilots should relight the engines using the windmill restart procedure,24

which required an airspeed of at least 300 knots. The procedure indicated that an altitudeloss of 5,000 feet could be expected when accelerating from 240 to 300 knots.

The FDR resumed operation about 2159:16.25 FDR data showed that the auxiliarypower unit (APU) was supplying electrical power to the airplane, both engines’ N1indications continued to decrease, and both engines’ N2 indications were at zero. FDRdata also showed that the airplane’s altitude was 29,200 feet and that its airspeed was178 knots.

20 The 27º AOA value is the physical limit of the sensor that measures this parameter. AOAs that arephysically higher were recorded as this limit.

21 FDR data and the CVR recording indicated that the engines were operating normally before theupset.

22 For information about this checklist, see section 1.17.2.2.23 This requirement was a checklist memory item.24 A windmill restart is an emergency in-flight procedure in which the effect of ram airflow passing

through the engine provides rotational energy to turn the engine’s core. 25 At that time, the cabin altitude warning signal was being recorded by the FDR. The FDR did not

record the cabin altitude warning signal any time before the loss of engine power or the beginning of the gapin FDR data. The CVR recorded the first activation of the cabin pressure warning about 2157:04. Forinformation about the cabin pressurization system and oxygen mask use during the flight, see sections 1.6.2and 1.18.1, respectively.


About 2200:38, the captain told the first officer to increase the airspeed to above300 knots, and the first officer acknowledged this instruction. FDR data showed that theairplane pitched down to -4.4º and accelerated to an airspeed of 200 knots but that, duringthe next 25 seconds, the airplane pitched up to 0º while its airspeed remained at 200 knots.About 1 minute later, the captain again told the first officer to increase the airspeed to300 knots. FDR data showed that the airplane pitched down to -7.5º and accelerated to anairspeed of 236 knots (the maximum airspeed achieved during the windmill restartattempt) but that, during the next 22 seconds, the airspeed decreased to 200 knots.26

About 2201:51, the captain stated, “we’re not getting any N two at all. So we’regonna have … to go to … thirteen thousand feet. We’re going to use the APU bleed air[restart] procedure.”27 Shortly afterward, the captain resumed the double engine failurechecklist, which indicated that pilots were to maintain between 170 and 190 knots untilthey were ready to initiate the APU bleed air restart procedure.

About 2203:09, the controller asked the flight crew about the nature of theemergency. The captain responded, “we had an engine failure up there … so we’re gonnadescend down now to start our other engine.” About 2203:30, the captain stated, “we’redescending down to thirteen thousand to start this other engine,” and the controllerreplied, “understand controlled flight on a single engine right now.” FDR data showedthat, during the next several minutes, four APU-assisted engine restarts were attempted,but the N2 speed for both engines remained at zero throughout the restarts. About 2206:40,the controller asked the flight crewmembers whether they wanted to land; the captainreplied, “just stand by right now we’re gonna start this other engine and see … ifeverything’s okay.” About 2206:54, the controller informed the flight crew that JEF wasup ahead, and the captain acknowledged this information.

About 2208:17, the CVR recorded the captain stating, “switch.” About 2209:02,the captain instructed the first officer to tell the controller that they needed “to get direct to[an] airport neither engine’s started right now.” The first officer informed the controller forthe first time of the double engine failure,28 and the controller then asked the pilots if theywanted to go direct to JEF. The captain stated, “any airport and closest airport,” and thefirst officer told the controller, “closest … airport. We’re descending fifteen hundred feetper minute we have … nine thousand five hundred feet left.”

Between about 2210:21 and about 2211:20, the controller provided informationabout the winds, the approach frequency, and the localizer frequency for an instrumentlanding system (ILS) landing to runway 30 at JEF. About 2212:24, the first officer askedthe controller where to look for the airport,29 and the controller provided position,distance, and heading information. About 1 minute later, the controller provided additionallocation information for JEF. About 2213:37, the captain asked the first officer whether

26 For more information about these and other events during the airplane’s descent, see section 1.16.1.3.27 Bleed air refers to pressurized air that is provided by the engines or the APU.28 At this time, the first officer was recorded transmitting from the right seat, which was his proper

position in the cockpit. 29 The airplane had descended out of clouds at an altitude of about 5,000 feet.


the airplane was aligned with the runway, and the first officer notified the controller thathe did not see the runway. The controller provided further directional information, and thefirst officer told the controller that he thought he had the approach end of the runway insight. The controller received no further transmissions from the flight crew.

About 2214:02, the first officer told the captain that he had the runway in sight.The captain questioned the first officer about the location of the runway and then stated,about 2214:17, “we’re not gonna make this.” About 2214:38, the captain stated, “is there aroad? We’re not gonna make this runway.” Radar data showed that the airplane thenturned left and headed toward a straight and lit section of highway. About 2214:46, thecaptain stated, “let’s keep the gear up … I don’t want to go into houses here.” About2214:53, the final radar return was received when the airplane was about 0.58 nauticalmile southeast of the crash site and at an altitude of 930 feet.

About 2214:54, 2214:58, and 2215:00, the CVR recorded the enhanced groundproximity warning system (GPWS) alerts “too low gear,” “too low terrain,” and “pull up,”respectively. About 2215:03, the CVR recorded the captain stating, “we’re gonna hithouses,” and, about 2 seconds later, the enhanced GPWS alert “pull up.” About 2215:06,the CVR recorded a sound similar to an impact and stopped recording about 1 secondafterward.

1.2 Injuries to PersonsTable 1. Injury chart.

1.3 Damage to AirplaneThe airplane was destroyed by impact forces and a postcrash fire.

Injuries Flight Crew Cabin Crew Passengers Other Total

Fatal 2 0 0 0 2

Serious 0 0 0 0 0

Minor 0 0 0 0 0

None 0 0 0 0 0

Total 2 0 0 0 2


1.4 Other DamageTrees were damaged during the accident sequence. Also, a garage and items in the

backyards of six houses were damaged by the impact of the airplane, a property line fencewas damaged when the No. 1 engine separated from the airframe after impact, and nearbyhouses received heat damage from the postcrash fire.

1.5 Personnel Information

1.5.1 The Captain

The captain, age 31, held an airline transport pilot certificate and a FederalAviation Administration (FAA) first-class medical certificate dated July 22, 2004, with alimitation that required him to wear corrective lenses while exercising the privileges ofthis certificate. The captain received a type rating on the CL-65 in August 2004. (TheCL-600-2B19 airplane is included in the CL-65 type rating.)

The captain was hired by Pinnacle Airlines in February 2003. According to thecaptain’s application for employment, he graduated in May 1995 from Embry-RiddleAeronautical University in Florida with a bachelor of science degree in aeronauticalscience. The application indicated that the captain worked as a flight instructor forEmbry-Riddle Aeronautical University from August 1996 to October 1999, a first officeron the British Aerospace Jetstream at Trans States Airlines from January 1999 toMay 2000, and a captain on the Beech 1900 at Gulfstream International Airlines fromJune 2000 to September 2002.30 The captain’s résumé indicated that he had received FAAhigh altitude physiological training.

Pinnacle Airlines employment and flight records indicated that the captain hadaccumulated 6,900 hours of total flying time, including 5,055 hours as apilot-in-command, 973 hours on the CL-65, and 150 hours as a CL-65 pilot-in-command.He had flown 667, 154, and 75 hours in the 12 months, 90 days, and 30 days, respectively,before the accident. The captain’s last recurrent ground training occurred on December 8,2003; his last recurrent proficiency check was on August 10, 2004; and his lastpilot-in-command line check occurred on August 26, 2004. FAA records indicated noaccident or incident history or enforcement action, and a search of records at the NationalDriver Register found no history of driver’s license revocation or suspension.

According to his wife, the captain was in good health and exercised regularly. Hedid not smoke and used alcohol only occasionally. He did not take prescription ornonprescription medicine (other than daily vitamins and ibuprofen when needed). He hadnot been sick in the days before the accident. He would generally wake at 0745 and go tosleep no later than 2300 when on reserve and not flying. A company first officer (whoknew the captain since they were at Gulfstream International Airlines) stated that no

30 In August 2000, the captain received a type rating on the Beech 1900.


significant changes had occurred in the captain’s life during the year preceding theaccident.

The captain went to a movie with his wife on the evening before the accident. Onthe day of the accident, he went to a park with his family, went shopping, and went out forlunch. The captain was on standby status at Detroit Metropolitan Wayne County Airport(DTW), Detroit, Michigan, on the day of the accident. Crew scheduling notified him about1700 that he was to “deadhead” (that is, travel on a company flight as a nonrevenuepassenger) on flight 5809 from DTW to LIT, reposition the accident airplane from LIT toMSP, and remain in Minneapolis overnight. Flight 5809 departed DTW about 1919 andarrived at LIT about 2036. Two Northwest Airlines31 customer service agents, who spokebriefly with the captain after he deplaned, reported that he “looked fine,” “did not appeartired,” and “appeared to be in a good mood.” The captain’s wife did not think that he hadflown with the accident first officer before the accident flight.

The captain’s wife stated that he had experienced only one previous emergencyduring his flying career, which occurred while he was with Gulfstream InternationalAirlines. She stated that the landing gear did not extend and that the flight crew had to usethe emergency extension procedures. She also stated that the captain had received a letterof commendation from the president of Gulfstream International Airlines, whichrecognized the captain’s actions during a landing in challenging crosswind conditions.

1.5.1.1 Pilot and Simulator Instructor Interviews Regarding the Captain

Most pilots who had flown with the captain had favorable comments about hisflying abilities. These pilots stated that the captain operated the airplane in a standardmanner, demonstrated good crew resource management (CRM) skills, and was “easy toget along with.” Also, a first officer (who had known the captain since they were atGulfstream International Airlines) stated that the captain was “the best stick and rudderpilot he had ever flown with.” Another first officer stated that the captain set a tone in thecockpit that made the first officer feel comfortable bringing concerns to the captain’sattention.

A first officer who flew with the captain from October 7 to 8, 2004, stated that theflights were conducted in a standard manner with no deviations from the flight crewoperating manual (FCOM). Another first officer (who had also known the captain sincethey were at Gulfstream International Airlines) stated that the captain did not seem to be arisk taker. All of the pilots who were interviewed after the accident stated that the captainhad never discussed flying at 41,000 feet.

The simulator instructor who conducted part of the captain’s upgrade trainingstated that, during training, the captain did not always perform checklists according tocompany procedures and did not always use the correct checklists.32 For example, theinstructor stated that the captain would, at times, misstate the status of a checklist item,

31 At LIT, Northwest Airlines provided ground support for Pinnacle Airlines.32 The simulator instructor stated that he debriefed the captain about these deficiencies.


read a checklist item but not accomplish it, or take action on an airplane system that wasnot the one noted in the checklist. The instructor also stated that the captain would, attimes, see the appropriate checklist displayed in an engine indicating and crew alertingsystem (EICAS) message33 but would still call for the wrong checklist. In addition, theinstructor stated that the captain flew the airplane “just fine” but that his biggestweaknesses were his critical decision-making and judgment. In contrast, the captain’ssimulator partner thought that all checklists during their training had been performedaccording to company procedures and stated that, during the debriefing sessions, theinstructor did not make any negative comments about the captain’s decision-making.

Another simulator instructor who conducted part of the captain’s upgrade trainingstated that he had no recollections of the captain rushing checklists and that the captain’sjudgment was “above average.” A check airman who conducted part of the captain’supgrade operating experience stated that the captain displayed the profile that he lookedfor in upgrading captains: proficiency, judgment, initiative, leadership, deliberate andthoughtful actions, and no rushing.

1.5.2 The First Officer

The first officer, age 23, held a commercial pilot certificate with airplane single-and multiengine land and instrument airplane ratings. The first officer also held an FAAfirst-class medical certificate dated January 14, 2004, with a limitation that required himto wear corrective lenses while exercising the privileges of this certificate.

The first officer was hired by Pinnacle Airlines in April 2004. According to thefirst officer’s application for employment, the first officer attended Broward CommunityCollege in Florida from May 2001 to December 2003 and received an associate of sciencedegree in professional pilot technology. In October 2002, the first officer began training atGulfstream Academy of Aeronautics and subsequently became a first officer on theBeech 1900 for Gulfstream International Airlines.34

Pinnacle Airlines employment and flight records indicated that the first officer hadaccumulated 761 hours of total flying time, including 222 hours as a CL-65second-in-command. He had flown 380, 192, and 60 hours in the 12 months, 90 days, and30 days, respectively, before the accident. The first officer’s initial proficiency checkoccurred on June 27, 2004. FAA records indicated no accident or incident history or

33 Pinnacle Airlines’ checklists were typically used with EICAS messages. Pilots were to call for thechecklist noted in an EICAS message and then use that checklist to guide them through a sequence ofactions.

34 The first officer’s personnel file contained letters of recommendation from Gulfstream InternationalAirlines pilots. For example, in an August 10, 2003, letter, a captain who had trained and flown with the firstofficer wrote that he displayed “capable skills in maneuvering the aircraft smoothly and safely” and that heexhibited “excellent situational awareness and decision-making ability.” The letter further stated that thefirst officer showed strict adherence to company procedures, emphasized CRM, and had strongcommunication skills.


enforcement action, and a search of records at the National Driver Register found nohistory of driver’s license revocation or suspension.

According to his father, the first officer was in good health and exercised regularly.The first officer was a nonsmoker and used alcohol only occasionally. He was not takingany prescription or nonprescription medications. The first officer was described assomeone who had a positive attitude, was motivated, and was happy to be with PinnacleAirlines.

The first officer was on reserve duty beginning on October 11, 2004. He flew a tripfrom October 11 to 12 and was on reserve duty on October 13. As with the captain, thefirst officer was notified during the afternoon of October 14 of the repositioning flight, andhe departed DTW about 1919 as a deadheading crewmember and arrived at LIT about2036. A Northwest Airlines customer service agent, who spoke briefly with the firstofficer after he deplaned, reported that he “appeared to be in a good mood” and “did notseem tired.” According to his father, the first officer had not previously flown with theaccident captain.

1.5.2.1 Pilot and Simulator Instructor Interviews Regarding the First Officer

During postaccident interviews, captains who had flown with the first officerdescribed him as a confident pilot who was good with checklists and as someone whowould ask questions if he did not understand something. The captain who flew with thefirst officer on the trip from October 11 to 12, 2004, described him as an “average” firstofficer. This captain did not note any problems with checklists during the trip. All of thepilots interviewed stated that the first officer had not expressed curiosity about flying at41,000 feet.

A simulator instructor who trained the first officer stated that he was a good pilotwith a positive attitude. The instructor also stated that he was not concerned about the firstofficer’s abilities and that he would have made a fine captain. The simulator check airmanwho conducted the first officer’s simulator checkride stated that he did a good job on thecheckride and that he made only minor mistakes that were not uncommon for first officersto make.

1.6 Airplane InformationThe accident airplane, a Bombardier CL-600-2B19, serial number (S/N) 7396, was

delivered new to Pinnacle Airlines on May 18, 2000. At the time of the accident, theairplane had accumulated 10,168 total flight hours and 9,613 total flight cycles.35

35 An aircraft cycle is one complete takeoff and landing sequence.


On the day of the accident, another flight crew was scheduled to fly the accidentairplane from LIT to MSP. The flight crew rejected the takeoff after receiving an EICASmessage that read “R 14TH DUCT.” The airplane returned to the gate,36 and amaintenance contractor was called to examine the problem. The maintenance contractorcould not find the source of the problem, so two Pinnacle Airlines mechanics weredispatched from Memphis, Tennessee, to LIT to resolve the problem. The mechanicsfound that the No. 2 engine pylon 14th stage bleed air duct sensing loop had some chafingdamage where it passed through a rib in the pylon. The loop was replaced, and the No. 2engine was tested for about 30 minutes. The airplane was then released for service.

The airplane’s actual takeoff weight was 39,336 pounds, which was less than themaximum takeoff weight of 53,000 pounds. The takeoff center of gravity (cg) was21.6 percent mean aerodynamic chord, which was within the cg limits of 9.0 to35.0 percent.

1.6.1 Powerplants

The airplane was equipped with two General Electric (GE) CF34-3B1 turbofanengines. The No. 1 (left) engine, S/N 872746, was installed on the airplane onApril 6, 2004, and had accumulated 8,856 total flight hours and 8,480 total flight cyclessince new. The No. 2 (right) engine, S/N 873514, was installed new on the airplane onOctober 23, 2003, and had accumulated 2,304 total flight hours and 1,971 total cyclessince new.

The No. 1 engine’s fuel control had been replaced on January 3, 2002. The No. 1engine had been removed from another company airplane on October 30, 2003 (when theengine had accumulated 7,594 flight hours and 7,422 flight cycles); afterward, PinnacleAirlines maintenance personnel replaced the stage 9 compressor blades, the scavenge oillube pump, and the fan inlet sensor and installed the engine on the accident airplane. TheNo. 2 engine’s fan inlet sensor and fuel control unit had been removed from an engine onanother company airplane and were installed on the accident airplane’s No. 2 engine. Noother major engine components had been changed on either engine since the time ofmanufacture.

1.6.2 Systems

The airplane was equipped with a Honeywell (formerly Garrett Airesearch)GTCP 36-150RJ APU. The APU can provide electrical and pneumatic power to theairplane’s systems when the main engines are not powering those systems. The maximumaltitude permitted for the use of bleed air with this APU is 15,000 feet, although designdocuments showed that the APU was capable of providing pneumatic power at21,000 feet. For the CRJ-200, the APU can be started when the airplane is at an altitudethat is less than 30,000 feet. A load control valve (LCV) was mounted on the APU

36 Afterward, the crew and passengers were put on another airplane so that the flight to MSP couldresume.


pneumatic supply outlet. When the LCV opens, it allows pneumatic power from the APUto become available to each engine’s 10th stage bleed air valves37 and then to the airturbine starters (ATS), which turn energy from pneumatic air into mechanical torque forrotation of the engine cores. Figure 1 shows components in the airplane’s pneumaticsupply and start systems, including the APU, LCV, 10th stage bleed air valves, and ATS.

Figure 1. Components in the CRJ Pneumatic Supply and Start Systems

The pneumatic system also supplied air to the cabin pressurization system, whichwas digitally controlled to maintain a maximum cabin altitude of 8,000 feet (± 100 feet).The system was designed to provide a cabin altitude/cabin pressure warning38 at a cabinaltitude of 10,000 feet and to deploy cabin oxygen masks at a cabin altitude of 14,000 feet.

The airplane was equipped with a stall protection system (SPS), which providesthe flight crew with warnings of an impending stall condition.39 The stickshaker is onecomponent of the system.40 After stickshaker activation, the SPS protects againstaerodynamic stalls via a stickpusher.

37 FDR data showed that the LCV opened at an altitude of 13,000 feet. The LCV remained open duringeach of the four APU-assisted engine restart attempts and then closed afterward. Bombardier maintenancetraining manuals indicated that opening the LCV at altitudes above 15,000 feet would result in a cockpitwarning. The accident CVR recorded a cockpit warning associated with the LCV opening. FDR data fromthe accident flight showed that the LCV opened when the airplane was at 15,400 feet and then closed a fewseconds later.

38 When this warning occurs, “CABIN ALT” is displayed on the EICAS, and “cabin pressure” isannounced in the cockpit.

39 SPS activation criteria depend on the airplane’s AOA, as measured by vanes mounted on the forwardfuselage.

40 In addition to the stickshaker, stall warnings are indicated by activation of the engine autoignition,autopilot disconnect, aural warning, and red “STALL PUSH” lights on the glareshield.


1.6.3 Maintenance Records

The Pinnacle Airlines maintenance program requires a service check every 3 daysand a routine check every 100 hours. The last service check performed on the accidentairplane was on October 13, 2004, and the last routine check was performed on October 7,2004; no discrepancies were noted during either check.

The Pinnacle Airlines maintenance program also requires an A check every500 hours; this check consists primarily of system inspections, lubrications, andadjustments. The last A check was accomplished on August 18, 2004. Also, themaintenance program includes C checks, which involve detailed visual inspections offlight controls, powerplants, and structures. Until the time that an airplane accumulates8,000 total flight hours, the C check is performed at phased intervals to prevent theairplane from being out of service for an extended period of time. Once the airplaneaccumulates 8,000 flight hours, it must be out of service for an extended period of time toperform the full C check.41 The accident airplane’s full C check was performed inSeptember 2003.

Finally, Pinnacle Airlines uses a calendar inspection program for “maintenancesignificant items” and “structural significant items.” These inspections occur every 12, 24,36, 48, 60, 72, and 96 months. The last inspections that were performed on the accidentairplane were the 24- and 48-month inspections, which occurred concurrently duringFebruary and March 2004.

The airplane’s daily aircraft maintenance logs between April 2001 andOctober 2004 showed no discrepancies related to the circumstances of this accident. Also,the airplane’s discrepancy list for the 30 days before the accident showed no evidence ofany major repairs to the airplane.

1.7 Meteorological InformationJEF has an automated surface observing system (ASOS), which is maintained by

the National Weather Service (NWS). The ASOS records continuous information on windspeed and direction, cloud cover, temperature, precipitation, and visibility.42 The ASOStransmits an official meteorological aerodrome report (known as a METAR) each hour.The 2153 METAR indicated the following: wind from 290º at 6 knots, visibilityunrestricted at 10 miles, ceiling overcast at 4,400 feet, temperature 10º C, dew point 5º C,and altimeter 29.63 inches of mercury (Hg). The 2253 METAR indicated the following:wind from 270º at 5 knots, visibility unrestricted at 10 miles, sky clear below 12,000 feet,temperature 8º C, dew point 5º C, and altimeter 29.63 inches of Hg.

41 After the first full C check at 8,000 hours, all subsequent full C checks are performed every4,000 hours.

42 Cloud cover is expressed in feet above ground level. Visibility is expressed in statute miles.


The closest upper air sounding43 along the route of flight was from Springfield,Missouri, which was about 50 miles west-southwest of the upset location and about90 miles south of the accident site. The 1900 sounding showed that the approximate baseof the clouds was at an altitude of 4,135 feet, the freezing level was at an altitude of4,699 feet, the top of the clouds was at an altitude of about 7,000 feet, and another cloudlayer was at an altitude of about 18,000 feet. The atmosphere was classified as stable. Themaximum wind was from 345º at 60 knots at an altitude of 29,000 feet. The wind wasfrom 315º at 48 knots at an altitude of 41,000 feet.

The NWS issued Airman’s Meteorological Information (AIRMET)44 Tango forturbulence, which was valid from 2045 on October 14 to 0300 on October 15, 2004, alongthe route of flight and over the location of the upset. The AIRMET indicated thatoccasional light to moderate turbulence could be encountered between 20,000 and39,000 feet.

1.8 Aids to NavigationNo problems with any navigational aids were reported.

1.9 CommunicationsThe airplane was handled by air traffic controllers at LIT, the Memphis ARTCC,

and the Kansas City ARTCC. No communications problems were reported.

1.10 Airport InformationJEF is located 2 miles northeast of Jefferson City at an elevation of 549 feet. The

airport has two runways, 9/27 and 12/30. The flight crew was attempting to land onrunway 30, which had an ILS available. The airport’s ATC tower was closed at the time ofthe accident.

1.10.1 Air Traffic Control

ATC radar data were primarily obtained from the Kansas City ARTCC long rangeradar site located in Crocker, Missouri.45 Additional radar data were provided by the LITATC tower, the Memphis ARTCC, and the Airport Surveillance Radar-9 radar site locatedin Columbia, Missouri.

43 An upper air sounding shows the wind profile and the expected clear air turbulence, cloud layers, andicing potential.

44 An AIRMET is an in-flight advisory that notifies en route pilots of the possibility of encounteringhazardous flying conditions that may not have been forecast at the time of a preflight briefing.

45 At this radar site, air route surveillance radar data are obtained once every 12 seconds.


The Kansas City ARTCC comprises several sectors (altitudes/areas ofresponsibility), and the sectors are denoted by numbers. The sector 30 radar controller atthe ARTCC handled the accident flight when it was at an altitude of 24,000 feet andabove, and the sector 53 radar controller at the ARTCC handled the airplane when it wasbelow an altitude of 24,000 feet. The National Transportation Safety Board conductedpostaccident interviews with these controllers.

The sector 30 radar controller first became aware of the accident flight when heaccepted a handoff from the sector 29 radar controller.46 The flight was at an altitude of41,000 feet at the time. The sector 30 radar controller stated that he asked the flight crewto confirm that the type of airplane was actually a CRJ because the flight level seemed“odd” for that airplane model. The radar controller stated that the flight crew confirmedthat the airplane was a CRJ and that, 1 minute later, the flight crew requested a loweraltitude. The radar controller stated that he was coordinating the descent with the sector 29controller when he heard one of the pilots saying something similar to “emergency” in astressed voice. The sector 30 radar controller stated that he immediately handled theairplane as if it were experiencing an emergency, notified his supervisor of the situation,and instructed the sector 29 controller to turn away another airplane from the accidentairplane.

The sector 30 radar controller stated that the flight crew did not provide him withmuch information about the in-flight situation, so he assumed that the flight crew did notwant to deal with additional ATC transmissions during this time. The airplane’s data blockhad lost altitude information, so the controller began switching between the main andbackup radar systems to monitor altitude and rate of descent. The controller stated that hedid not receive an altitude readout until the airplane reached 33,000 feet.

The sector 30 radar controller stated that the flight crew requested a descent to13,000 feet. The controller stated that he first coordinated with underlying radar sectors topermit the airplane to descend below 24,000 feet and that he then issued the clearance to13,000 feet. The controller stated that he then instructed the flight crew to contact thesector 53 radar controller. The sector 30 radar controller assisted the sector 53 radarcontroller by referring to the JEF approach charts for information about the ILS frequencyand the airport beacon.

The sector 53 radar controller first became aware of the accident flight when sheoverheard the sector 30 controller notifying their supervisor of an emergency airplane. Shethen began monitoring the airplane from her position. The sector 53 radar controller statedthat, once the pilots were on the sector 53 frequency and reported that the airplane wasdescending to 13,000 feet, she advised them of the airports that were available for alanding. After the flight crew requested a lower altitude for the engine restart, thecontroller assigned an altitude of 11,000 feet. Shortly afterward, the airplane descendedthrough 10,500 feet, and the flight crew notified the controller of a double engine failure.

46 The sector 29 controller was also responsible for the accident flight when it was at an altitude of24,000 feet and above.


The sector 53 radar controller stated that she immediately called Mizzou approach controlto advise that the airplane had lost power and would be descending to land at JEF.

The sector 53 radar controller stated that she directed the flight to JEF andprovided the minimum instrument altitude for the area and the localizer frequency for therunway 30 ILS approach. The controller stated that the pilots asked her where the airportbeacon was located, and she provided them with a description of the beacon in relation tothe runway. The controller stated that she received no further voice transmissions from theflight crew and that the last radar contact with the airplane was at an altitude of about900 feet. The controller stated that, after losing radar contact, she tried to contact theairplane several times but received no response.

In addition, ATC transcripts showed that, after the loss of radar contact with theairplane (the final radar return was received about 0.58 nautical mile southeast of the crashsite and at an altitude of 930 feet), the Mizzou approach controllers reported the locationof a probable accident to the police and fire services in Jefferson City.

1.11 Flight Recorders

1.11.1 Cockpit Voice Recorder

The airplane was equipped with a Fairchild model A100S solid-state CVR,S/N 02804. The CVR did not sustain any heat or structural damage, and the audioinformation was extracted normally and without difficulty.

The CVR recording contained four channels of audio data.47 The first channelrecorded excellent audio quality information from the observer’s seat audio panel.48 Thesecond channel recorded excellent audio quality information from the copilot’s station.The third channel recorded good audio quality information from the pilot’s station. Thefourth channel contained fair audio quality information from the cockpit area microphone.A transcript was prepared of the entire 30-minute 23-second digital recording (seeappendix B).

The first, second, and third channels all contained audio information from theairplane’s aural warning system, including the synthesized voice of the crew alertingsystem. The fourth channel also recorded aural warnings but did so via a cockpit speaker.

47 The Safety Board rates the audio quality of CVR recordings according to a five-category scale:excellent, good, fair, poor, and unusable. Appendix B describes each of these categories.

48 Federal regulations state that the first channel is to record audio information from the third flightcrewmember station. Because a third flight crewmember was not required for the CRJ-200, the source forthe information recorded by the first channel could be determined by the operator. The first channel did notrecord any intercom or radio communications.


1.11.2 Flight Data Recorder

The accident airplane was equipped with an L3 Communications Fairchild modelF-1000 FDR, S/N 01094. The FDR recorded flight information in a digital format usingsolid-state memory as the recording medium.

The FDR was sent to the Safety Board’s laboratory for readout and evaluation. TheFDR was in good condition, and the data were extracted normally. About 51 hours of datawere recorded on the FDR, including about 55 minutes of data from the accident flight.During the flight, power was lost to the FDR, which resulted in a data dropout of about3 minutes 56 seconds (2155:20 to 2159:16). Data recorded immediately before thedropout, from 2155:16 to 2155:19, and immediately after the FDR was back on line, from2159:16 to 2159:21, had some parameters that appeared to be valid but others thatappeared to be invalid.

The accident airplane’s FDR was not in compliance with the requirements in14 CFR 121.344, Appendix M. Specifically, the source of the vertical accelerationparameter was not updated at a rate that met the required recording intervals. Also, thepitch attitude parameter was recorded at a higher sample rate than the source was updated.On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to the FAAbecause of problems with the quality of FDR data recorded by several regional jetairplanes, including the CRJ. Section 1.18.3.3 provides information about this safetyrecommendation.

1.12 Wreckage and Impact InformationThe main airplane wreckage was located at an elevation of 740 feet. Several tree

strikes were identified along the airplane’s flightpath before the main wreckage location.The direction of the tree strikes was on a magnetic heading of about 304º. The first signsof tree strikes were found on a tree that was located about 474 feet from the mainwreckage location; the top branches of the tree were severed very slightly. The first treethat showed signs of a major impact was located about 425 feet from the main wreckagelocation. The tree’s limbs were severed at a height of 43 feet above ground level, andsmall fragments of the airplane wreckage were found near this tree.

About 14 feet of the outboard left wing, including the winglet, was located about187 feet before the main wreckage location. This wing section showed two largeindentations in the leading edge; two large tree limbs with the same diameter as theindentations were located within 12 feet of the wing section. The tree that was struck waslocated 190 feet before the left wing section.

About 92 feet before the main wreckage location, a large tree was slightlydamaged on one side. A large group of trees about 18 feet to the right of that tree alsoshowed slight damage. The airplane traveled through the 18-foot gap between the trees.The left wing impacted the ground at the same location as a small tree that was sheared ata height of about 12 feet above ground level. A large ground scar measuring about 87 feet


in length and having a shape similar to the top of the airplane’s nose was located 30 feetbefore the main wreckage location. The ground scar contained material from the top of theforward cabin.

Measurements of tree strikes along the flightpath showed that the airplane wasdescending at a pitch attitude of about -2.5º. The airplane struck the first trees in a 40ºleft-wing-down attitude. The airplane impacted the ground nose first in a close-to-invertedattitude. All of the airplane wreckage was accounted for at the accident site. The airplane’swreckage extended along a 1,234-foot path, beginning with the initial impact point (thefirst major tree strike), continuing through six residential backyards, and ending past aresidential street.

1.12.1 Powerplants

Examination of the engines at the accident site found that neither engine exhibitedclassic rotational damage49 or ingestion evidence. The engines were disassembled andinspected at GE’s manufacturing facility in Lynn, Massachusetts. The engine core rotorswere rotated, and neither core was found seized. Teardown inspections found nomechanical failures or evidence of seizure in either engine.50 A materials investigation ofthe high pressure turbine seal hardware found no abnormal rotational marks.

1.12.2 Systems

Inspection and testing of the airplane’s pneumatic supply and start systems foundnothing that would have prevented them from providing torque to either engine.

The APU was found in its installed position with light soot on its top surfaces. TheAPU was subsequently examined at Honeywell’s facility in Phoenix, Arizona. Aborescope inspection noted no internal physical damage. After the replacement of animpact-damaged part, the APU operated and exceeded the performance requirements for anewly overhauled unit.

The LCV was found with light soot and no observable damage. Duringpostaccident testing, the LCV hesitated initially before opening fully the first time, and,with each subsequent opening, the LCV opened more freely than the previous time. (Thefirst test was performed with opening commands that were intentionally applied slowerthan normal,51 and the subsequent tests were performed at the conditions under which the

49 Classic rotational damage includes reverse bending of rotating airfoils and circumferential scrapingsignatures along fan blade paths.

50 The inspection disclosed thermal damage to the turbine blades in the No. 2 engine that would haveimpeded the engine from producing thrust but would not have prevented the core from rotating. (Theinspection found no preimpact damage to the No. 1 engine.)

51 Other possible reasons for the initial hesitation included the impact forces that caused thesurrounding structure (including the APU mount and housing where the LCV was positioned) to buckle andthe dirt and debris that was found inside the APU and the LCV.


LCV was designed to operate.) The testing showed that the LCV was capable of allowingpneumatic power from the APU to enter the 10th stage bleed air valves and then the ATS.

Flight control cable continuity could not be established because of the impactdamage to the forward portion of the airplane, but CVR and FDR evidence indicated thatthe flight controls operated normally during the flight.

1.13 Medical and Pathological InformationTissue specimens from the captain and the first officer tested negative for ethanol

and a wide range of drugs, including major drugs of abuse.

1.14 FireThe airplane wreckage showed no evidence of an in-flight fire. Major portions of

the wreckage showed postcrash fire damage.

1.15 Survival AspectsAccording to the Boone/Calloway County Medical Examiner’s office, the cause of

death for the captain and the first officer was blunt force trauma.

1.16 Tests and Research

1.16.1 Aircraft Performance Study

The Safety Board performed an aircraft performance study for this accident. FDR,CVR, weather, and ATC radar and communications data were used to develop the timehistory of the accident airplane’s motion. These data were time correlated. The studyresults for the airplane’s performance during the climb to 41,000 feet, aerodynamic stalland upset event, and descent and glide are presented in sections 1.16.1.1 through 1.16.1.3,respectively.

1.16.1.1 Climb to 41,000 Feet

FDR data showed that the airplane’s initial takeoff rotation occurred about 2121:45and that, 3immediately after liftoff, the pitch angle of the airplane was about 6º. Fourseconds later, when the airplane was at an altitude of about 450 feet, the first of threepitch-up maneuvers during the ascent occurred when the flight crew moved the control


column to 8º ANU,52 causing the airplane’s pitch angle to increase to 22º and resulting in avertical load of 1.8 Gs. Immediately afterward, the FDR recorded stickshaker andstickpusher activations, a full AND control column deflection, a decrease in pitch angle,and a drop in vertical load to 0.6 G. After the stickpusher deactivation, the airplanecontinued to climb at a pitch angle between 10º and 14º ANU.

About 2127:17, when the airplane was in level flight at an altitude of 15,000 feetand with the autopilot in vertical speed mode, the second pitch-up maneuver during theascent began. FDR data showed that the control column moved to 3.8º ANU, causing theairplane’s pitch angle to increase to 17º and resulting in a vertical load of 2.3 Gs. About2127:26, the flight crew moved the control column 2.5º AND, decreasing the pitch angleto about 6º and the vertical load to 0.3 G about 5 seconds later. Afterward, the flight crewmoved the control column 3.4º ANU. Between about 2128:40 and about 2128:43, theflight crew made a left rudder input of 4.2º, a right rudder input of 6.0º, and a left rudderinput of 0.4º,53 resulting in lateral loads of -0.16 G, 0.34 G, and -0.18 G, respectively.About 17 seconds later, the flight crew made a right rudder input of 7.7º.

About 2132:40, when the airplane was in level flight at an altitude of 24,600 feetwith the autopilot engaged and a vertical speed of 600 fpm, the third pitch-up maneuverduring the ascent began. The flight crew moved the control column 4º ANU, whichincreased the airplane’s pitch angle to more than 10º, resulted in a vertical load of 1.87 Gs,and increased the airplane’s vertical speed to 5,000 fpm for several seconds. About2132:46, the flight crew disconnected the autopilot and moved the control column to 3.8ºANU, which increased the airplane’s pitch angle to about 15º. About 2133:10, the flightcrew reengaged the autopilot with a vertical speed of 3,000 fpm, which was reduced to1,400 fpm by 2133:30 and 1,000 fpm by 2134:00.

The autopilot remained engaged in vertical speed mode between the altitudes of34,000 and 41,000 feet. Between 34,000 and 35,000 feet, the airplane’s vertical speed was1,000 fpm, the calculated Mach number was about 0.60, and the engines maintained N1indications of 95.5 percent. As the airplane climbed through 35,000 feet, its vertical speedwas reduced to 0. About 2141:00, the airplane leveled off at an altitude of 36,500 feet.Within the next minute, the calculated Mach number increased to 0.64. When the climbresumed, the airplane’s vertical speed was 500 fpm, and the engines’ N1 indications were

52 According to FDR documentation, the control column has a range from -11.9º (forward) to 13.8º(aft).

53 On November 10, 2004, about 1 month after this accident, the Safety Board issued SafetyRecommendation A-04-59 to the FAA as a result of its findings from the November 2001 American Airlinesflight 587 accident in Belle Harbor, New York. Safety Recommendation A-04-59 asked the FAA to “developand disseminate guidance to transport-category pilots that emphasizes that multiple full deflection,alternating flight control inputs should not be necessary to control a transport-category airplane and thatsuch inputs might be indicative of an adverse aircraft-pilot coupling event and thus should be avoided.” OnJanuary 9, 2006, the FAA stated that it issued Safety Alerts for Operators 05002, “Multiple Full Deflection,Alternating Flight Control Inputs,” which urged directors of safety, directors of operations, and pilots oftransport-category airplanes to be familiar with the content of the Airplane Upset Recovery Training Aid andto pay particular attention to the cautions against alternating flight control inputs and aircraft-pilotcouplings. As a result, the Board classified Safety Recommendation A-04-59 “Closed—Acceptable Action”on June 9, 2006.


about 95.7 percent. About 2144:00, the airplane was climbing through 37,400 feet. Theairplane continued to climb at a vertical speed of 500 fpm during the next 7 minutes untilreaching an altitude of 41,000 feet. During this time, the calculated Mach numberdecreased to 0.57, the pitch angle increased from 3º to 6º, and the engines’ N1 indicationsdecreased to 94.7 percent.

Once the airplane reached the selected altitude of 41,000 feet, the autopilotreduced the airplane’s vertical speed to 0, and the airplane leveled off. During the next3 1/2 minutes, the calculated Mach number decreased to 0.53, the pitch angle and AOAincreased to about 7º, and the engines’ N1 indications decreased to 94.2 percent.

1.16.1.2 Aerodynamic Stall and Upset Event

About 2154:34, the airplane’s airspeed was 150 knots.54 About 2 seconds later, thestickshaker activated, causing the autopilot to disconnect; at that point, the airplane’sAOA had increased to about 7.5º. Within the next second, the control column moved toabout 0º. About 3 1/2 seconds after autopilot disconnect, the flight crew moved the controlcolumn 3.5º ANU. The flight crew then moved the control column back toward neutraluntil it reached about 1.1º ANU. During the next few seconds, the flight crew moved thecontrol column to 4º ANU, which caused the pitch angle to increase to about 8.5º.

By 2154:45, the AOA had increased to the point that both the stickshaker and thestickpusher activated. The control column moved forward rapidly in response to theactivation of the stickpusher, decreasing the pitch angle to -3.5º, the AOA to 0º, and thevertical load to 0 G. The stickpusher then deactivated, and the flight crew moved thecontrol column past neutral to about 5º ANU, which caused the pitch angle to increase to8º and the AOA to increase to 11º.

During the next 8 seconds, while the airspeed was at 160 knots, the stickshaker andstickpusher activated twice. The stickpusher, during both activations, moved the controlcolumn forward in response, and, once the AOA decreased, the control column was thenmoved past neutral to an ANU position.55 After the stickpusher activations, the controlcolumn was moved to about 5.2º and about 5.9º ANU. About 2154:51, the No. 2 engine’sN1 indication decreased from 94 to 84 percent, and the pitch angle decreased to -19.5ºabout 2154:55. One second later, after the stickpusher had activated and released for thethird time, the flight crew moved the control column to 6.8º ANU (which was the largestANU movement during the pitch oscillations), and the vertical load decreased to -0.8 G.

By 2154:57, the stickshaker had activated for the fifth time, and the stickpusherhad activated a fourth time, pushing the control column to full nose down (where itremained for the next 4 1/2 seconds). Despite the activation of the stickpusher, the airplaneentered an aerodynamic stall as the motion of the airplane continued to increase the AOA

54 All airspeeds in sections 1.16.1.2 through 1.16.1.4 are knots calibrated airspeed.55 Public hearing testimony by Bombardier Aerospace indicated that, without pilot input, the control

column position would return to near neutral after stickpusher cancellation resulting from the AOAdecreasing below the deactivation angle.


to its maximum ANU measurable value of 27º. Both engines’ fuel flow indicationsdecreased to near zero by 2154:58, and the airplane’s pitch angle reached a maximumANU value of 29º at 2154:59. During this time, the airplane’s recorded airspeed was74 knots, and its recorded altitude increased from 41,000 to 42,000.56

As the pitch angle began to decrease, a left rolling motion began, which eventuallyreached 82º left wing down. The pitch angle reached a maximum AND value of 32º byabout 2155:06. During the next 14 seconds, the flight crew made several control column,control wheel, and rudder inputs to recover the airplane from the upset. During therecovery, the stickpusher activated three more times, both engines’ fuel flow indicationsremained near zero, and both engines’ N1 settings decreased to about 28 percent. The FDRstopped recording data about 2155:20. The last reliable N2 speed recorded by the FDRbefore it stopped operating was 46 percent for the No. 1 engine and 51 percent for theNo. 2 engine.

1.16.1.3 Descent and Glide Performance

The FDR resumed recording data about 2159:16 when the airplane was at analtitude of 29,200 feet. During the 4-minute gap between recorded FDR data, the engineshad stopped operating.

During the initial part of the descent, the airspeed increased, the pitch angle variedbetween 1º and -4º, and the descent rate reached a maximum of 5,000 fpm. A maximumairspeed of 236 knots was reached about 2202:12 when the airplane descended through analtitude of 20,500 feet. At an altitude of about 20,300 feet, the airplane leveled off forabout 20 seconds and then began to descend again at a rate between 1,800 and 2,000 fpmand at an airspeed of about 200 knots.

About 2204:46, the airplane descended through an altitude of 15,000 feet, and theairspeed began to decrease as the pitch angle increased. During the next several minutes,the airspeed remained about 170 knots, and the descent rate was between 1,000 and2,000 fpm.

About 2209:06, when the airplane was at an altitude of 10,000 feet, the flight crewnotified the air traffic controller that the airplane needed to land at the closest airport. Atthat point, the airspeed varied between 180 and 206 knots, and the descent rate variedbetween 300 and 3,200 fpm. Also, several short control column movements occurred,causing the pitch angle to vary from 3º AND to 2º ANU and the vertical load to increase to1.3 Gs.

The Safety Board obtained glide performance calculations for the accidentairplane from Bombardier Aerospace. The reference airspeed for the glide performancecalculations was 170 knots, which was the best glide airspeed for the accident airplane’s

56 The recorded airspeed and altitude values may not be accurate because, according to Bombardier, thestatic source error corrections that are programmed into the air data computers are not calibrated for the highAOA (greater than 27º) experienced at this point in the flight.


estimated gross weight.57 Data from the accident airplane’s FDR showed that the flightspoilers deployed to 5.6º from 28,000 feet until the end of the recording. The glideperformance calculations included the drag from the flight spoilers and the air-drivengenerator (ADG).58 According to the glide performance calculations, at an altitude of30,000 feet, six airports (including JEF) were within the airplane’s best glide range. JEFwas located about 74 miles north-northeast of the upset location.59 The five other airportswere the following:60

• Waynesville Regional Airport (TBN), Fort Leonard Wood, Missouri, whichwas located about 23 miles north-northeast of the upset location;

• Floyd W. Jones Lebanon Airport (LBO), Lebanon, Missouri, which waslocated about 25 miles northwest of the upset location;

• Lee C. Fine Memorial Airport (AIZ), Kaiser Lake Ozark, Missouri, which waslocated about 44 miles north of the upset location;

• Springfield-Branson Regional Airport (SGF), Springfield, Missouri, whichwas located about 50 miles west-southwest of the upset location; and

• Rolla National Airport (VIH), Rolla/Vichy, Missouri, which was located about53 miles north-northeast of the upset location.

At an altitude of 20,000 feet, five airports (including JEF) were within theairplane’s best glide range.61 At an altitude of 10,000 feet, only one airport (AIZ) waswithin the airplane’s best glide range; JEF was just outside the best glide range at thataltitude. Figure 2 shows the glide distances to the six airports for the accident airplane.

57 A best glide airspeed provides the airplane with the most distance forward for a given loss of altitude.58 The ADG deploys automatically and provides backup power when the engines no longer power the

primary electrical generators.59 As stated in section 1.16.1.2, the upset event is characterized by the 82º left-wing-down rolling

motion and the -32º pitch angle.60 These five airports had runways in excess of 5,000 feet. 61 SGF was no longer within the airplane’s best glide range.


Figure 2. Glide Distances for the Accident Airplane

1.16.2 Cockpit Voice Recorder Studies

The Safety Board conducted a CVR study to determine flight crew seatingpositions. The study correlated CVR and ATC audio information with FDR microphone


key data. The audio communications system on the accident airplane sent pilot stationposition (but not radio source) information to the FDR for its microphone key parameter.This information and voice identification information from the CVR allowed the Board todetermine which pilot was transmitting on the radio from which crew seat position.

The correlation determined that, during takeoff, the captain made radiotransmissions from the left seat (the first officer was recorded from the right seat). Thecorrelation also determined that, about 6 minutes into the ascent, through the upset event,and until after several engine restart attempts, the captain made radio transmissions fromthe right seat (the first officer was recorded from the left seat). Finally, the correlationdetermined that, after the flight crew requested to land at JEF until the last transmission tothe controller, the first officer made radio transmissions from the right seat (the captainwas not recorded during this time period). The flight crew seating positions aresummarized in table 2.

Table 2. Flight Crew Seating Positions

Note: In the CRJ-200, the captain is normally seated on the left, and the first officer is normally seated on the right.

a Although the CVR and FDR were functioning during this time, they did not record any cockpit audio or microphone keydata from the left audio panel after 2205:53. The lack of CVR and FDR information from an audio panel indicates that itsdedicated controller board has lost power (even though the rest of the audio communication system remains powered) orthat the panel selector switch has been set to “EMER” (emergency).

The CVR study also documented events related to engine checklist use and flightcrew oxygen mask use; some of these events are shown in table 3. Oxygen use by theflight crew is further discussed in section 1.18.1.

Table 3. Engine Checklist and Oxygen Mask Use Events

Time Left audio panel Right audio panel

2121:00 to 2124:14 Captain First officer

2126:43 to 2206:59 First officer Captain

2209:06 to 2214:39 No informationa First officer

Time Event

2156:42 Start of double engine failure checklist.

2157:04 Crew alerting system warning of cabin pressure.

2158:21 Comment to use oxygen mask.

2158:41 Sound similar to oxygen flow starting in oxygen mask.

2201:36 Double engine failure checklist—windmill restart procedure.


In addition, the Safety Board conducted a CVR sound spectrum study to determinewhether any noise was recorded by the CVR during the four APU-assisted engine restartattempts that would indicate ATS operation. Each CVR channel was examined across thefull frequency range for signal changes, appearances, and disappearances, but nothingassociated with any of the engine restart attempts was found.

1.16.3 Engine Tests

The accident FDR showed decreasing engine core-driven accessory parameterindications62 after the double engine failure. About 15 minutes afterward, engine oiltemperature cooling rates leveled off momentarily, and slight engine hydraulic pumppressure indications were noted. This signal activity was inconsistent with the engines’zero N2 indications.

Engine tests were performed at Pinnacle Airlines’ maintenance facility inMemphis and the Bombardier Aerospace Flight Test Center in Wichita, Kansas. A test toevaluate the engine oil temperature anomalies demonstrated that, after a period of normalengine operation, changes in engine oil temperature that were consistent with the accident

Time Event

2202:14 Double engine failure checklist—APU bleed air restart procedure.

2204:06 Comment to use oxygen masks.

2204:09 Sound similar to oxygen flow starting in oxygen mask.

2204:13 Comment regarding cabin altitude of 15,400 feet and need to be on oxygen.

2206:23 Sound similar to oxygen mask removal.

2207:04 Double engine failure checklist—relight attempt of No. 1 engine using APU bleed airprocedure.

2207:20 Sound similar to oxygen flow in oxygen masks.

2207:41 Double engine failure checklist—relight attempt of No. 2 engine using APU bleed airprocedure.



2209:32 Double engine failure checklist—relight attempt of engine using APU bleed airprocedure.

2211:42 Double engine failure checklist—relight attempt of engine using APU bleed airprocedure.

62 These parameters included fuel flow, oil pressure, oil temperature, and engine hydraulic pressure.


FDR anomalies would result when APU-assisted restarts were attempted with the enginecore rotor locked. The test also demonstrated that the FDR could record small hydraulicpressure signals while the engine core was prevented from rotating.

A test to evaluate the slight increases (25 to 30 pounds per square inch gauge[psig]) in core-driven hydraulic pump pressure indications63 showed that hydraulic pumppressure would begin to indicate on the FDR with about 35 rpm of core rotation. Anothertest showed that N2 signals would begin to indicate on the FDR and in the cockpit withabout 70 rpm of core rotation.

A test demonstrated that the ATS was capable of rotating an engine core from zeroN2 with 10th stage duct pressures as low as 6 psig (as detected by the EICAS) and that 25-to 30-psig hydraulic pump pressures could be recorded on the FDR as long as engine corerotation was sustained at a speed of about 35 rpm. This test also showed that, by the timethat engine core rotation had reached a speed of 75 rpm, hydraulic pump pressures hadincreased quickly to 1,500 psig.

1.16.4 Load Control Valve Simulation Study

As stated in section 1.6.2, the LCV allows pneumatic power from the APU tobecome available to each engine during the start sequence. In the pneumatic system, theLCV and its associated ducts are the components that support both engines. Thus, amalfunction of the LCV could result in a failure to achieve indications of engine rotationon either engine. To determine the minimum amount of LCV opening needed to result ininitial engine rotation, as indicated by FDR data, and whether a minimum LCV openingvalue during the four APU-assisted engine restart attempts could be determined, theSafety Board conducted a computer-based simulation study that was validated againstexisting flight test data provided by Bombardier.

For the simulation study, the Safety Board used the results of previous ground andflight tests that provided data about the minimum torque output required from the ATS toinitiate detectable core rotation from 0 rpm. As indicated in section 1.16.3, the testsshowed that about 35 rpm of core rotation was needed to detect an indication of hydraulicpump pressures64 on the FDR and that about 70 rpm of core rotation was needed to detectan indication of N2 on the FDR and in the cockpit. The tests also showed, and data fromHoneywell indicated, that about 6 psig at the ATS inlet with 27.5 pounds per minute ofcorrected airflow65 could result in detectable core rotation.

FDR data for the accident flight showed that the LCV was open throughout eachAPU-assisted restart attempt. Although the LCV normally opens fully (85º) during an

63 Normal hydraulic system operating pressure is 3,000 psig, and signals of 25 to 30 psig are outside ofthe system transducer’s validated measurement range.

64 The hydraulic pump is driven by engine core rotation.65 Because airflow changes based on altitude and temperature, corrected airflow provides a common

reference point that recalculates airflow in terms of a standard day at sea level (that is, 59º F and29.92 inches of Hg).


APU-assisted engine restart, the FDR parameter for the LCV position shows that the valveis open once it reaches a position that is greater than 4.8º from its normally closedposition.

The simulation showed that, for a normally functioning engine, the LCV needed tobe open by about 8º to produce enough torque at the ATS output to initiate detectable corerotation from a stopped condition.66 However, at this 8º setting, the LCV-supplied airvolume that reached the ATS start valve diminished once the start valve opened, and thenthe LCV and other downstream pneumatic system valves closed because the pressureprovided was insufficient to keep them opened. This result was not consistent with theFDR data from the accident flight, which showed that the 10th stage bleed air valvesremained open from 25 seconds (in accordance with guidance on the double engine failurechecklist, as shown in appendix C) to about 105 seconds during all four engine restartattempts and that the LCV remained open during each restart attempt. Also, the CVR didnot include any discussion to indicate that the 10th stage or start valve functions deviatedfrom what the pilots would normally observe during an APU-assisted start on the ground.

The simulation also showed that, with an LCV opening of at least 18º, all of thepneumatic supply valves would be kept open, as was seen on the accident FDR. An LCVopening of at least 18º was also sufficient to initiate and maintain detectable rotation of thecore rotor from 0 rpm.67

1.17 Organizational and Management InformationPinnacle Airlines, Inc., is a wholly owned subsidiary of Northwest Airlines, Inc.,

and is based in Memphis. The airline was established in 1985 as Express Airlines I.Between 1985 and 2000, Express Airlines I operated turboprop airplanes only. In 2001,Express Airlines I began integrating CRJ turbojet airplanes into its fleet and, in 2002,changed its name to Pinnacle Airlines. By 2003, Pinnacle Airlines had phased outturboprop airplanes from its operations and operated CRJ turbojet airplanes only. At thetime of the accident, the company employed about 900 pilots and had a fleet of 110 CRJsthat provided service to destinations in the United States and Canada.

1.17.1 Ground School and Simulator Training

1.17.1.1 Upset Training

Pinnacle Airlines provided upset training to newly hired pilots during groundschool and simulator training. According to a Pinnacle Airlines ground school instructor,pilots received 6 hours of upset training during the general operational subjects module.

66 This initiation was based on ground start conditions that were corrected for altitude. However, thepressure, altitude, and temperature did not account for airspeed, which would have reduced the requiredonboard pneumatic pressure and flow requirements.

67 The rotation would not likely be fast enough for an engine’s starting sequence to be completed.


The subjects covered during this training included swept-wing design characteristics andhigh altitude aerodynamics.68 Also, pilots received a copy of the Pinnacle Airlines JetUpset Student Guide.

A Pinnacle Airlines simulator instructor stated that pilots received about20 minutes of upset training in the simulator. The training consisted of Mach tuck andMach buffet demonstrations69 and unusual attitude recoveries. Also, the simulatorinstructor discussed operations at high altitudes where low indicated airspeeds yieldedhigh true airspeeds (and a high Mach number) at high AOAs, but the training did notinclude any maneuvers or stalls at high altitudes.

After the accident, Pinnacle Airlines revised the upset training sections of itsground school instructor guide, ground school curriculum, and the Jet Upset StudentGuide to include stalls and airplane maneuvers at an altitude of 37,000 feet. Also, theairline enhanced upset training in the simulator by having pilots perform maneuvers athigh altitudes.

1.17.1.2 High Altitude Climbs

According to Pinnacle Airlines ground school instructors, high altitude climbs,recommended climb profiles, and altitude and climb capability charts70 were discussedwith newly hired pilots during the general operational subjects module (specifically, theupset training and performance sections of the module). Simulator instructors stated thatthey discussed high altitude climbs and recommended climb profiles with newly hiredpilots during pre- and postsimulator briefings but did not demonstrate or have the pilotspractice high altitude climb techniques.

The Pinnacle Airlines Flight Operational Quality Assurance (FOQA) program71

manager stated that the CRJ service ceiling of 41,000 feet was discussed during groundschool. Company check airmen, simulator instructors, and pilots stated that operations at41,000 feet were neither discussed nor demonstrated during simulator training. Asimulator instructor stated that 41,000 feet was not an altitude at which pilots wanted tooperate very often.

68 High altitude is 25,000 feet and above.69 A Mach tuck is the result of an aft shift in the center of lift, causing a nose-down pitching moment. A

Mach buffet is the airflow separation behind a shock wave pressure barrier that results when the airflow overflight surfaces exceeds the speed of sound.

70 See section 1.17.2.1 for more information about Pinnacle Airlines’ altitude and climb capabilitycharts.

71 A traditional FOQA program is an FAA-approved, voluntary program for the routine collection andanalysis of FDR data gathered during aircraft operations. At the time of the accident, Pinnacle Airlines didnot have a traditional FOQA program in place; instead, the program was designed to manage the checkairmen through flight monitoring. At the time of the June 2005 public hearing for this accident (seeappendix A), Pinnacle Airlines was working toward the deployment of a traditional FOQA program. InOctober 2006, the company reported that it was operating an FAA-approved FOQA program and wascollecting an average of 2,000 hours of data each month.


In November 2004, Pinnacle Airlines revised the performance section of itsground school instructor guide to include more specific high altitude climb informationand procedures, including a minimum climb profile speed above 10,000 feet of 250 knotsor 0.7 Mach, whichever was lower.72 Also, the company added a high altitude climbscenario to its simulator training.

1.17.1.3 Double Engine Failure

According to postaccident interviews with the CRJ program manager, checkairmen, simulator instructors, and pilots at Pinnacle Airlines, the double engine failurechecklist items were discussed during ground school and one of the simulator briefings.They stated that the simulator sessions did not include a scenario in which a double enginefailure had occurred or a scenario in which the ADG had been deployed. Also, they statedthat, during ground school, pilots were required to pass written and oral examinations onall memory checklist items, including those for the double engine failure procedure (seesection 1.17.2.2).

In December 2004, Pinnacle Airlines issued a revised simulator instructor guide toinclude single and double engine failures at 35,000 feet during new hire and captainupgrade simulator training. Pilots are now required to use the ATS-assisted restartprocedures for a single engine failure and windmill restart procedures for a double enginefailure. These exercises familiarize the pilots with emergency power-only procedures andthe effects of ADG deployment. The revised simulator instructor guide also includes anexercise during which the pilots start the APU as the airplane descends through30,000 feet.

1.17.1.4 Stall Recognition and Recovery Training

Pinnacle Airlines’ stall recognition and recovery simulator training was conductedat an altitude of 10,000 feet and with various airplane configurations. For all of theapproach-to-stall profiles, the pilot was expected to initiate actions to recover from animpending stall when the first indication of a stall (which was usually the activation of thestickshaker) occurred.73 One purpose of the training was to ensure that a pilot couldprevent a full stall from occurring. Another purpose of the training was to demonstrate thata pilot had mastered the airplane throughout its speed range and was able to initiate astandard recovery using the appropriate flight control inputs and callouts. The training didnot include high altitude stalls, full stalls, or recoveries from full stalls.

The Pinnacle Airlines CRJ program manager stated that the company’sapproach-to-stall profiles did not normally progress to stickpusher activation, which hethought was consistent with industry stall training. He stated that a pilot might experience

72 This information was also incorporated into Pinnacle Airlines’ CRJ FCOM Operating Limitationssection, as indicated in section 1.17.2.1.

73 The Pinnacle Airlines CRJ FCOM, volume 1, Flight Instruments—Air Data System, datedJanuary 2003, showed that the low speed cue on the airspeed indicator was another indication to the flightcrew of an impending stall.


stickpusher activation during simulator training if the pilot overcorrected in response tothe stickshaker. According to the program manager, if this situation were to occur,Pinnacle Airlines instructed the pilot to work with the stickpusher upon activation todecrease the AOA and gradually return to the starting altitude for the maneuver. Also, theprogram manager stated that pilots were required to test the stickpusher before the firstflight of each day as part of the preflight check of the SPS.

In December 2004, Pinnacle Airlines issued a revised simulator instructor guide toinclude, for new hire, captain upgrade, and recurrent simulator training, a high altitudestall demonstration with the autopilot engaged74 and a high altitude stall buffet margindemonstration.

1.17.1.5 Crew Resource Management Training

At the time of the accident, Pinnacle Airlines provided 8 hours of CRM training topilots during initial training. The course was presented in lecture format and includedPowerPoint slides, scenario-based questions, handouts, and videotapes. The topicscovered during the course were resource management, human factors, communication,workload management, team building, and technical proficiency. Accident events andscenarios were also discussed. During recurrent and upgrade training, pilots received a2-hour version of the course.

Pinnacle Airlines managers, instructors, and pilots stated that CRM concepts werereinforced and evaluated during simulator training. They stated that crew coordination andassertiveness were stressed and that instructors discussed crew performance indicatorsduring debriefings.

The director of flight operations at Pinnacle Airlines stated that the key measuresof CRM effectiveness were crew coordination, workload management, communications,and situational awareness. This director also stated that he had seen pilots using goodCRM skills during line operations. The Pinnacle Airlines FOQA manager and a firstofficer with the company stated that CRM training provided first officers with the toolsthey needed to challenge captains if necessary.

After the accident, Pinnacle Airlines restructured CRM training to provideadditional focus on decision-making and the need to adhere to standard operatingprocedures.

1.17.1.6 Leadership Training

At the time of the accident, Pinnacle Airlines provided a 2-hour leadership trainingmodule during the 8-day captain upgrade training course. Topics covered during thetraining were leadership authority, responsibility, and leadership styles.

74 For the training that was in effect at the time of the accident, the autopilot was used only for theapproach to stall in the landing configuration.


Pinnacle Airlines had a target of 10 percent for its captain upgrade first-timefailure rate. In July 2004, when the rate was 22 percent, FAA and company personnel metto discuss how to reduce the failure rate. Pinnacle Airlines personnel stated that datashowed that the most cited reasons for upgrade failure were leadership and judgment. TheFAA principal operations inspector (POI) stated that this finding showed that the failureswere primarily because of deficiencies in “captain thinking skills” rather than “stick andrudder skills.” As a result, Pinnacle Airlines management decided to place more emphasison leadership during upgrade training75 and increase the minimum number of hoursrequired for upgrade operational experience76 from 10 to 25.

A Pinnacle Airlines simulator instructor worked with the company’s CRJ leadinstructor to develop a new 8-hour leadership course. The course includes modules onleadership, authority, and responsibility; briefing and debriefing scenarios;decision-making processes, including those during an emergency; dry run line-orientedflight training scenarios; and risk management and resource utilization. The FAAobserved the leadership course in November 2004 as part of the approval process;afterward, Pinnacle Airlines added the course to upgrade training. In October 2006, thecompany reported that about 92 percent of the pilots upgrading to captain passed thetraining the first time and that the overall captain upgrade training pass rate was95 percent.

1.17.2 Flight Manuals

1.17.2.1 High Altitude Climbs

At the time of the accident, the Pinnacle Airlines CRJ FCOM, volume 2,Maneuvers, page 7, dated June 2004, listed the following three climb profiles: high speed,320 knots/0.77 Mach; normal speed, 290 knots/0.74 Mach; and long range,250 knots/0.70 Mach. Pinnacle Airlines indicated that, to maintain an airspeed at or above250 knots/0.70 Mach, the airplane’s vertical speed during the climb should be at least300 fpm. Also, the Pinnacle Airlines CRJ FCOM, volume 2, Operating Limitations,page 4, dated April 2003, stated that the maximum operating altitude for CRJs was41,000 feet.

75 During postaccident interviews, Pinnacle Airlines’ FOQA manager stated that a weakness in captainswas their leadership skills, and Pinnacle Airlines’ director of flight operations stated that managementtraining would help captains with their decision-making.

76 Upgrade operational experience, which occurs after a new captain has completed upgrade training, iswhen the new captain conducts flight operations in the presence of a check airman.


The Pinnacle Airlines CRJ FCOM, volume 2, Performance, pages 50 through 52,dated June 2002, presented altitude and climb capability charts. Pilots were required toconsult these charts anytime a flight was operating above 36,000 feet because of a flightmanagement system (FMS) limitation above that altitude.77 A climb capability chartshowed the 300-fpm climb ceiling for an airspeed of 250 knots/0.70 Mach and themaximum cruise thrust limit altitude for cruise speeds of 0.74, 0.77, and 0.80 Mach andlong range cruise. This information was provided for airplane weights between 34,000 and52,000 pounds and outside air temperatures from the International Standard Atmosphere(ISA) temperature to ISA + 10º C.78

After the accident, Pinnacle Airlines added the following restriction to its CRJFCOM volume 2 Operating Limitations section: “minimum climb profile speed above10,000 feet MSL will be 250/.70M whichever was lower.” Also, Pinnacle Airlines addedthe altitude and climb capability charts to its Quick Reference Handbook (which isrequired to be on all company airplanes) to make it easier for pilots to reference theinformation. In addition, on October 22, 2004, Pinnacle Airlines issued AlertBulletin 04-54, which stated that all company flights were not to exceed an altitude of37,000 feet and that flight crews were not to accept or request ATC clearance above thisaltitude. Finally, the Pinnacle Airlines Ground School Instructor’s Guide, Performancesection, page 35, dated November 2004, stated the following: “when a 300 FPM rate ofclimb cannot be achieved at the minimum climb speed, the aircraft will be leveled off anda new altitude coordinated with ATC.”

1.17.2.2 Double Engine Failure

The Pinnacle CRJ FCOM, volume 2, Emergency Procedures, pages 8 through 13,dated July 2003, detailed the procedure for an in-flight double engine failure.79 For thisprocedure, the flying pilot is responsible for calling for the double engine failure checklistmemory items, and the nonflying pilot is responsible for performing the memory itemsand reading and performing the remaining items on the checklist.

77 FCOM volume 2, Operating Limitations, pages 30 and 31, dated June 2004, stated that “the FMScalculated thrust setting must not be used if the pressure altitude is greater than 36,000 feet.” TheBombardier chief pilot stated that the reason for the FMS limitation above 36,000 feet was because of theinaccurate calculations above that altitude. Further, according to Bombardier, at altitudes above 36,000 feet,the conversion from static air temperature to the International Standard Atmosphere (ISA) deviation isincorrect within the FMS, resulting in an error in the N1 indication at those altitudes. (A detailed explanationof ISA appears in the next footnote.) Bombardier’s Flight Planning and Cruise Control Manual and QuickReference Handbook contain charts that show the proper N1 indication for altitudes between 36,000 and41,000 feet.

78 The International Civil Aviation Organization defines ISA as a sea-level pressure of 1,013.2 millibarsat a temperature of 15º C, with temperature decreasing at a standard rate of 2º C per 1,000 feet until reachingthe tropopause (the boundary between the troposphere—the lowest region of the earth’s atmosphere—andthe stratosphere—the middle region of the earth’s atmosphere). In the standard atmosphere, the tropopauseis at 36,000 feet. On the night of the accident, the tropopause was at 27,600 feet, and the temperature at41,000 feet, -47.1º C, was 9.4º C more than the ISA temperature for that altitude.

79 This information also appeared in the Quick Reference Handbook.


The double engine failure checklist required pilots to establish and maintain anairspeed of 240 knots (a memory item) until they were ready to restart the engines. Thedouble engine failure checklist also required pilots to use the windmill restart procedure ifthe airplane were at an altitude that was at or below 21,000 feet and above 13,000 feet.Requirements of the procedure included an airspeed of at least 300 knots to achieve an N2indication of 12 percent. The double engine failure checklist stated, “an altitude loss ofapproximately 5,000 feet can be expected when accelerating from 240 to 300 KIAS [knotsindicated airspeed].”

The double engine failure checklist also required pilots to use the APU bleed airrestart procedure if the airplane were at an altitude of 13,000 feet or below. This procedurerequired pilots to maintain an airspeed of between 170 and 190 knots until they were readyto initiate the APU-assisted engine restart. The procedure also required pilots to attempt tostart one engine at a time and that, if either engine were restarted, an N2 indication of28 percent was required before the thrust lever could be moved to idle.

The double engine failure checklist also stated that, if neither engine wererestarted, the flight crew should “consider a forced landing or a ditching.”

In May 2005, Pinnacle Airlines issued changes to its double engine failurechecklist. Specifically, the company rewrote the windmill relight procedure to make iteasier for pilots to follow. Also, the company incorporated other changes to the checklistbased on revisions made by Bombardier earlier that month to clarify the informationwithin the checklist. For example, the double engine failure checklist that was in effect atthe time of the accident indicated that 240 knots was the “target” airspeed to be maintaineduntil the flight crew was ready to restart the engines, but the revised checklist indicatedthat 240 knots was the “minimum” airspeed to be maintained. Also, the revised checklistincluded the following caution:

Failure to maintain positive N2 may preclude a successful relight. If required,increase airspeed to maintain positive N2 indication.

In addition, the windmill relight procedure included the following revised note andadded the following caution, respectively:

An altitude loss of approximately 5,000 feet can be expected when acceleratingfrom 240 to 300 KIAS and may require pitch attitudes of 10 degrees nosedown.[80]

300 KIAS or greater is required to achieve sufficient N2 for start. Airspeed mustbe maintained until at least one engine relights (stable idle) or start attemptsabandoned.

80 To this note, Pinnacle Airlines added, “if possible, crews should start accelerating to achieve300 KIAS upon reaching 21,000 feet.”


Appendix C shows Pinnacle Airlines’ double engine failure checklist at the time ofthe accident, and appendix D shows the airline’s revised double engine failure checklist.

1.17.2.3 Stall Protection System

The Pinnacle Airlines CRJ FCOM, volume 1, Flight Controls, pages 10-20 and10-21, dated January 2003, stated the following about the SPS:81

As a high AOA is approached, continuous ignition is activated. If the AOAcontinues to increase, the stick shakers are activated and the autopilot isdisengaged. If the AOA still continues to increase, the stick pusher mechanism isactivated, STALL lights on the glareshield panel flash red, and the warblersounds.

1.17.2.4 Flight Operations

Pinnacle Airlines’ Flight Operations Manual, Normal Procedures, section 4.30.1,“Safe Aircraft Operations,” dated August 2003, stated the following: “Pilots areprohibited from operating aircraft in a careless or reckless manner so as to endanger life orproperty. Maneuvers not necessary for the safe and orderly progress of flight areprohibited.” Section 4.30.2, “Absence From The Cockpit,” dated August 2003, stated that“all flight crewmembers shall remain at their duty stations during takeoff, landing andwhile enroute.”82

After the accident, Pinnacle Airlines issued a revision to its Flight OperationsManual. Normal Procedures, section 4.30.6, “Crew Composition,” dated May 2005,stated, “the minimum flight crew for all operations shall be a Captain and a First Officer.The Captain must occupy the left seat and the First Officer must occupy the right seat.”

1.17.3 Federal Aviation Administration Oversight

The Memphis Flight Standards District Office (FSDO) is responsible for oversightof Pinnacle Airlines. The supervisor of the Pinnacle Airlines certificate management unitstated that, after he was assigned to the position in October 2002, he appointed temporaryprincipal inspectors because he wanted a “fresh set of eyes” to evaluate the airline’scompliance with the Federal Aviation Regulations. He also stated that, before hisassignment, Pinnacle Airlines seemed to not pay much attention to the FAA and that theappointment of temporary principal inspectors would help the FAA achieve a fresh startwith the airline. He further stated that, as a result of this action, Pinnacle Airlines agreed toimprove its working relationship with the FAA.

81 A review of the SPS’ performance during the flight matched the system’s nominal performancerequirements.

82 According to the document, the only exception to this policy is when the absence of a flightcrewmember is necessary for the performance of duties in connection with the operation of the airplane orfor physiological needs.


In January 2003, the POI was removed from that position because he did not havea CRJ type rating. Three acting POIs (including the certificate management unitsupervisor) were on the Pinnacle Airlines certificate until the POI position waspermanently filled in July 2004. The new POI had been the assistant POI for PinnacleAirlines from July 2003 to January 2004, at which time he began 5 months of inspectortraining at the FAA Academy in Oklahoma City, Oklahoma. The POI currently has twoassistant POIs to help him with his workload.

1.18 Additional Information

1.18.1 Oxygen Mask Use During the Accident Flight

As stated in section 1.6.2, the cabin pressurization system was designed to providea cabin altitude/cabin pressure warning at a cabin altitude of 10,000 feet. The CVRrecorded the first activation of the cabin pressure warning about 2157:04. The FDR didnot record the cabin altitude warning signal about this time because FDR operation hadtemporarily ceased about 2155:20. The cabin altitude signal was recorded when FDRoperation resumed about 2159:16; at that time, the airplane was descending from analtitude of 29,200 feet. The FDR showed that the oxygen masks did not deploy until theairplane descended to an altitude of 22,531 feet (about 2201:45).

The CVR recorded, about 2204:06, the captain stating, “get on oxygen,” and,3 seconds later, a sound similar to oxygen flow in oxygen masks.83 About 2204:13, theCVR recorded the captain stating, “we’re at cabin altitude … fifteen thousand fourhundred. We need to be on oxygen.” About 2204:45, as the airplane descended through analtitude of 16,423 feet, the cabin altitude stopped climbing and started descending. About2206:23, the CVR recorded a sound similar to oxygen mask removal. The CVR againrecorded a sound similar to oxygen flow in oxygen masks about 2207:20 and then a soundsimilar to oxygen mask removal about 2208:11 and about 2208:15. The cabin altitudewarning signal was no longer present in the FDR recording when the airplane descendedthrough an altitude of 10,020 feet (about 2209:05).

1.18.2 Core Lock

During the investigation of this accident, the Safety Board learned that GE CF34-1and CF34-3 engines84 had a history of failing to rotate during in-flight restart attempts onairplanes undergoing production acceptance flight testing at Bombardier. Themanufacturers referred to this condition as “core lock.” Bombardier first identified thisproblem in 1983 during Challenger certification tests, and GE attributed the problem tointerference contact at an air seal in the high pressure turbine.

83 The CVR had previously recorded the first officer stating, “we need our oxygen masks,” about2158:21 and a sound similar to oxygen flow starting in oxygen masks about 2158:41.

84 Bombardier airplanes that are powered by either GE CF34-1 or CF34-3 engine models are theChallenger 601, Challenger 604, CRJ-100, CRJ-200, and CRJ-440.


The CF34 high pressure turbine air seals are designed to control cooling andbalance airflow. The seals include teeth on the rotating components that grind operatinggrooves into abradable surfaces on the stationary components. The efficiency of theseseals significantly affects engine performance, so the seals are designed to operate withminimal clearances.

Bombardier added a procedure that screened for core lock to the productionacceptance flight tests for its airplanes powered by CF34-1 and CF34-3 engines. At the timeof the accident, this screening procedure was as follows:

1. Climb to 31,000 feet.2. Retard the test engine throttle to idle and stabilize for 5 minutes.85

3. Shut down the test engine.4. Descend at 190 knots.5. Slow the aircraft until N2 is reduced to 0 percent.6. At 8 1/2 minutes from shutdown, push over to 320 knots.7. If N2 is 0 rpm at 21,000 feet, the engine is declared to be core locked.

Engines that are found to be core locked are reworked using an in-flight “grind-in”procedure that was designed to remove seal material at the interference location. Enginesthat undergo grind-in rework are then rescreened for core lock. The grind-in procedure isas follows:

1. ATS cross-bleed start.2. Ascend to 31,000 feet.3. Repeat core lock screening procedure but descend at an airspeed of

about 240 knots to establish 4 percent N2.4. Maintain 4 percent N2 for at least 8 1/2 minutes.5. Confirm that no core lock exists by repeating screening procedure.

As testimony during the Safety Board’s June 2005 public hearing on the PinnacleAirlines accident indicated, neither Bombardier nor GE considered core lock to be asafety-of-flight issue. The manufacturers claimed that engines that passed the screeningprocedure, with or without grind-in rework, would not core lock as long as the 240-knotairspeed was maintained.

Bombardier’s core lock screening procedure requires a cool-down period beforeengine shutdown to stabilize internal temperatures and clearances. However, this proceduredoes not produce the more severe thermal distress associated with the high power, highaltitude flameouts that were experienced during the accident flight. As stated in the SafetyBoard’s November 20, 2006, safety recommendation letter to the FAA,86 the successful

85 After the accident, Transport Canada mandated that Bombardier change the engine stabilization timefrom 5 to 2 minutes.

86 This letter transmitted Safety Recommendations A-06-70 through -76. For information about theserecommendations, see section 1.18.3.1.


demonstration of Bombardier’s flight test procedure might not ensure that an engine willnot experience core lock if the core is allowed to stop rotating after a high power, highaltitude flameout. In its letter, the Board noted that the No. 1 accident engine hadsuccessfully passed the screening procedure during initial production acceptance testing.87

The Board further stated that the successful demonstration of Bombardier’s flight testprocedure might not ensure that slowing the airplane to an airspeed of 170 to 190 knots issufficient to maintain core rotation during an attempted APU-assisted restart.

1.18.3 Previous Related Safety Recommendations

1.18.3.1 Core Lock

On November 20, 2006, the Safety Board issued Safety RecommendationsA-06-70 through -76 to the FAA to address the safety hazards associated with core lock,which can prevent pilots from restarting an engine after a double engine failure duringflight. Safety Recommendations A-06-70 through -76 asked the FAA to do the following:

For airplanes equipped with CF34-1 or CF34-3 engines, require manufacturers toperform high power, high altitude sudden engine shutdowns; determine theminimum airspeed required to maintain sufficient core rotation; and demonstratethat all methods of in-flight restart can be accomplished when this airspeed ismaintained. (A-06-70)

Ensure that airplane flight manuals of airplanes equipped with CF34-1 or CF34-3engines clearly state the minimum airspeed required for engine core rotation andthat, if this airspeed is not maintained after a high power, high altitude suddenengine shutdown, a loss of in-flight restart capability as a result of core lock mayoccur. (A-06-71)

Require that operators of CRJ-100, -200, and -440 airplanes include in airplaneflight manuals the significant performance penalties, such as loss of glide distanceand increased descent rate, that can be incurred from maintaining the minimumairspeed required for core rotation and windmill restart attempts. (A-06-72)

Review the design of turbine-powered engines (other than the CF34-1 andCF34-3, which are addressed in Safety Recommendation A-06-70) to determinewhether they are susceptible to core lock and, for those engines so identified,require manufacturers of airplanes equipped with these engines to perform highpower, high altitude sudden engine shutdowns and determine the minimumairspeed to maintain sufficient core rotation so that all methods of in-flight restartcan be accomplished. (A-06-73)

87 The No. 2 accident engine was installed new as a spare engine and was not subjected to the core lockscreening procedure because it applies only to engines that are installed in Bombardier’s productionairplanes.


For those airplanes with engines that are found to be susceptible to core lock(other than the CF34-1 and CF34-3, which are addressed in SafetyRecommendation A-06-71), require airplane manufacturers to incorporateinformation into airplane flight manuals that clearly states the potential for corelock; the procedures, including the minimum airspeed required, to prevent thiscondition from occurring after a sudden engine shutdown; and the resulting loss ofin-flight restart capability if this condition were to occur. (A-06-74)

Require manufacturers to demonstrate, as part of 14 Code of Federal RegulationsPart 25 certification tests, if restart capability exists from a core rotation speed of0 indicated rpm after high power, high altitude sudden engine shutdowns. Forthose airplanes determined to be susceptible to core lock, mitigate the hazard byproviding design or operational means to ensure restart capability. (A-06-75)

Establish certification requirements that would place upper limits on the value ofthe minimum airspeed required and the amount of altitude loss permitted forwindmill restarts. (A-06-76)

Appendix E shows the complete safety recommendation letter.

1.18.3.2 Crew Professionalism

On October 8, 1974, the Safety Board issued Safety Recommendations A-74-85and -86 as a result of the September 27, 1973, Texas International Airlines flight 655accident in Mena, Arkansas,88 and the September 11, 1974, Eastern Air Lines flight 212accident in Charlotte, North Carolina.89 The Board’s final report on the Texas InternationalAirlines accident stated that the captain failed to follow approved procedures. Theprobable cause of the Eastern Air Lines accident was the flight crew’s lack of altitudeawareness at critical points during the approach resulting from poor cockpit discipline(specifically, the crew did not follow prescribed procedures).90 SafetyRecommendation A-74-85 asked the FAA to do the following:

Initiate a movement among the pilots associations to form new professionalstandards committees and to regenerate old ones. These committees should:

a) monitor their ranks for any unprofessional performance.

88 For more information, see National Transportation Safety Board, Texas International Airlines, Inc.,Convair 600, N94230, Mena, Arkansas, September 27, 1973, Aircraft Accident Report NTSB/AAR-74/04(Washington, DC: NTSB, 1974).

89 For more information, see National Transportation Safety Board, Eastern Air Lines, Inc., DouglasDC-9-31, N8984E, Charlotte, North Carolina, September 11, 1974, Aircraft Accident ReportNTSB/AAR-75/09 (Washington, DC: NTSB, 1975).

90 The Safety Board’s safety recommendation letter cited five previous air carrier accidents as examplesof a “casual acceptance” of the flight environment (Martha’s Vineyard, Massachusetts, 1971; FortLauderdale, Florida, 1972; New Haven, Connecticut, 1972; Toledo, Ohio, 1973; and Boston, Massachusetts,1973). The letter added that the Eastern Air Lines accident also reflected “serious lapses in expectedprofessional conduct.”


b) alert those pilots who exhibit unprofessionalism to its dangers and try, byexample and constructive criticism of performance required, to instill inthem the high standards of the pilot group.

c) strengthen the copilot’s sense of responsibility in adhering to prescribedprocedures and safe practices.

d) circulate the pertinent information contained in accident reports to pilotsthrough professional publications so that members can learn from theexperience of others.

On October 17, 1974, the FAA stated that it considered it more appropriate to workwith airline management rather than pilot groups to increase and promote crew disciplineand professionalism. The FAA also stated that it discussed this subject at length with theAir Transport Association,91 which provided assurance that efforts would be made tostress the importance of professionalism. On March 10, 1977, the Safety Board classifiedSafety Recommendation A-74-85 “Closed—Acceptable Action.”

Safety Recommendation A-74-86 asked the FAA to do the following:

Develop an air carrier pilot program, similar to the general aviation accidentprevention program (FAA Order 8000.8A), that will emphasize the dangers ofunprofessional performance in all phases of flight. The program could bepresented in seminar form, using audio/visual teaching aids, to call to the pilots’attention all facets of the problem.

On October 17, 1974, the FAA stated that many airlines have established accidentprevention programs and have periodically conducted seminars. The FAA also stated thatit has participated in these seminars and would increase its participation in the future. TheFAA further stated that it would urge its field offices to emphasize the dangers ofunprofessional performance and that it would hold meetings with the Air TransportAssociation to discuss this subject. On March 10, 1977, the Safety Board classified SafetyRecommendation A-74-86 “Closed—Acceptable Action.”

1.18.3.3 Flight Data Recorder Data

On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to theFAA because of problems with the quality of FDR data recorded by several regional jetairplanes. Safety Recommendation A-03-15 asked the FAA to do the following:

Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, CanadairChallenger CL-600, and Fairchild Dornier 328-300 airplanes be modified with adigital flight data recorder system that meets the sampling rate, range, andaccuracy requirements specified in 14 Code of Federal Regulations Part 121.344,Appendix M.

91 The Air Transport Association is the trade organization of the largest U.S. airlines.


On June 9, 2005, the FAA stated the following:

• Regarding the Embraer 145 and 135, Embraer released Service Bulletin (SB)145-31-0042, Revision 2, to correct known FDR anomalies, and the BrazilianDepartment of Civil Aviation issued Airworthiness Directive (AD)2004-12-03, requiring incorporation of the Embraer SB within 18 months. TheFAA advised U.S. operators of the Embraer 145 and 135 of the Brazilian ADand planned to release a corresponding AD. (As of December 1, 2006, the FAAhad not issued the corresponding AD.)

• Regarding the Canadair CL-600-2B19 (CRJ-100, -200, and -440) andCL-600-2B16 (Challenger 604), the Canadian airworthiness authority,Transport Canada, reported that Bombardier confirmed that the FDR system onthese airplanes exhibited low update rates on the normal acceleration and pitchattitude parameters.92 Bombardier and Rockwell Collins, the supplier of thesystem that established the parameter update rates on these airplane models,were planning to develop a plan and schedule for correcting this problem. TheFAA was working with Transport Canada to get expeditious action fromBombardier on this issue.

• Regarding the Fairchild Dornier 328-300, AvCraft Aviation (which acquiredthe rights to the 328 program), in cooperation with Honeywell (themanufacturer of the 328-300 FDR system), completed an extensive review ofFDR data from two incidents and several flight tests. They concluded that allFDR parameters were updated at a rate equal to or exceeding those required by14 CFR 121.344, Appendix M, when the data were analyzed with the properframe rate and at the maximum accuracy.

On September 28, 2005, the Safety Board agreed that no problems existed with theFDR parameters on the Fairchild Dornier 328-300 airplane. The Board also stated that,pending the FAA’s issuance of an AD that mandated compliance with EmbraerSB 145-31-0042, Revision 2, and an AD that mandated correction to CRJ-100, -200, and-440 and Challenger 604 FDR systems, Safety Recommendation A-03-15 was classified“Open—Acceptable Response.”

1.18.4 Federal Aviation Administration Notice

On March 1, 2005, the FAA issued Notice N8000.296, “Pilot Judgment andDecisionmaking,” after six accidents that occurred between October and November 2004.These accidents were Pinnacle Airlines flight 3701, Corporate Airlines flight 5966,93 and

92 Bombardier indicated that other recorded parameters on the CRJ-100, -200, and -440 andChallenger 604 airplanes were updated at rates that were in compliance with the regulations. Bombardieralso noted that the update rates for all FDR parameters on CL-600-2C10 (CRJ-700) and CL-600-2D24(CRJ-900) airplanes complied with the regulations.

93 For more information, see National Transportation Safety Board, Collision With Trees and CrashShort of the Runway, Corporate Airlines Flight 5966, BAE Systems BAE J3201, N875JX, Kirksville,Missouri, October 19, 2004, Aircraft Accident Report NTSB/AAR-06/01 (Washington, DC: NTSB, 2006).


accidents involving a Learjet 35A at San Diego, California; a King Air 200 at Stuart,Virginia; a Challenger 600 at Montrose, Colorado; and a Gulfstream III at Houston,Texas.94

The notice was issued to POIs of operators of airplanes with 70 or fewer passengerseats, corporate managers and trainers, and individual pilots to encourage the promotionof “soft skills” as a first line of defense against accidents caused by lapses in humanperformance. The FAA defined soft skills as those that go beyond the technical knowledgeand psychomotor skills that are necessary to fly an airplane. Such skills include adherenceto standard operating procedures, decision-making, judgment, CRM, and professionalism.

The notice required POIs to convey information about the importance of soft skillsin preventing human error and the existing FAA guidance on that topic. The notice alsorecommended that operators ensure that their programs reflected the human factorprinciples that were outlined in FAA guidance about CRM and standard operatingprocedures. In addition, the notice indicated that individual pilots should examine theirown decision-making habits in terms of professionalism, thoroughness of preparation, andadherence to standard operating procedures. The notice expired on March 1, 2006.95 In aNovember 2006 memorandum to the Safety Board, the FAA stated that it incorporatedsoft skills into Part 121 CRM training requirements and that a rewrite (which is currentlyin progress) of FAA Order 8400.10, Air Transportation Operations Inspector’s Handbook,would emphasize soft skills.

1.18.5 Bombardier All Operator Message

On December 14, 2004, Bombardier issued an all operator message that includedthe following information about high altitude operations:

Climb profiles as detailed in the AFM [airplane flight manual] must be strictlyadhered to. Climbing below the recommended profile speed may place theairplane behind the energy curve when it arrives at the desired altitude and it maynot be capable of remaining at that altitude. This may be evident by an aircraftnose-high attitude and its failure to accelerate.

The autopilot should be engaged and performance closely monitored during theupper portion of the climb and immediately following the level off. When theselected altitude is reached, under normal conditions, the aircraft will accelerate tothe desired cruise speed.

94 For more information on these accidents, see LAX05FA015, IAD05MA006, DEN05MA029, andDCA05MA011, respectively, at the Safety Board’s Web site at <http://www.ntsb.gov>.

95 All FAA notices expire 1 year after issuance. Because the notices are temporary by nature, they arerarely renewed.


Situational awareness must be maintained at all times when the aircraft reachesthe desired cruising altitude. If the … [AOA] is excessively high, the performancemay be such that the aircraft is not capable of maintaining the altitude and theairspeed may begin to decay. Under these circumstances, a descent must beinitiated immediately.

Do not wait for the onset of continuous ignition or stick shaker before attemptinga descent from an altitude where continued operation is not possible. Descendimmediately.

In the event that a stick shaker/approach to stall occurs, the crew should expectthat a deliberate loss of altitude will likely be required in order to restore theaircraft to a normal energy state and to prevent an aerodynamic stall and possibledeparture from controlled flight.


2. Analysis

2.1 GeneralThe captain and the first officer were properly certificated and qualified under

Federal regulations. No evidence indicated any medical or behavioral conditions thatmight have adversely affected their performance during the accident flight. Flight crewfatigue and hypoxia were not factors in this accident.

The accident airplane was properly certified, equipped, and maintained inaccordance with Federal regulations. The recovered components showed no evidence ofany structural or system failures or any engine failures before the time of the upset event.Weather was not a factor in this accident. The accident was not survivable.

This analysis discusses the accident sequence, including the flight crew’s decisionto climb to 41,000 feet and the improper climb speed; the crew’s improper actions duringthe stall event; and the crew’s failure to restart the engines, inform air traffic controllers ofthe double engine failure, and initiate an emergency landing in a timely manner. Theanalysis also addresses flight crew training (in the areas of high altitude climbs, stallrecognition and recovery, and double engine failures) as well as flight crewprofessionalism. In addition, the analysis addresses problems with the quality of someparameters recorded by FDRs on regional jet airplanes, including the CRJ-200.

2.2 Accident Sequence

2.2.1 Climb to 41,000 Feet

The flight plan for the accident flight indicated that the planned cruise altitude was33,000 feet. However, the ATC and CVR transcripts showed the flight crew’s desire toclimb to an altitude of 41,000 feet, which is the CRJ maximum operating altitude.96

During postaccident interviews, Pinnacle Airlines pilots stated that some pilots hadexpressed curiosity about operating the airplane at 41,000 feet and that a “[flight level]410 club” existed at the airline.

When the airplane was at an altitude of 450 feet, the first of three aggressivepitch-up maneuvers during the ascent occurred. During the first maneuver, the flight crewmoved the control column to 8º ANU, causing the airplane’s pitch angle to increase to 22ºand resulting in a vertical load of 1.8 Gs. The maneuver also caused the stickshaker and

96 It is not known which pilot first suggested that the flight be operated at an altitude of 41,000 feet.However, CVR evidence showed that both pilots were willing participants in the decision to climb to41,000 feet.

Analysis 45 Aircraft Accident Report

stickpusher to activate. After stickpusher activation, the FDR recorded a full nose-downcontrol column deflection. When the airplane was at an altitude of 15,000 feet, the secondpitch-up maneuver occurred. The flight crew moved the control column to 3.8º ANU,causing the airplane’s pitch angle to increase to 17º and resulting in a vertical load of2.3 Gs. Afterward, the flight crew made rudder inputs of 4.2º to the left, 6.0º to the right,and 0.4º to the left followed 17 seconds later by a 7.7º right rudder input. When theairplane was at an altitude of 24,600 feet, the third pitch-up maneuver occurred. The flightcrew moved the control column to 4º ANU, causing the pitch angle to increase to morethan 10º and resulting in a vertical load of 1.87 Gs. The pilots’ intentional maneuvers,which were not required for any operational reason or safety consideration, placed theairplane in a flight regime that likely exceeded the airplane’s certificated flight envelope.97

The CVR recording showed that both pilots repeatedly expressed excitementbefore and after reaching the 41,000-foot altitude. For example, the CVR recorded thefirst officer stating, “man we can do it. Forty one it,” “there’s four one oh my man,” and“this is … great.” The CVR also recorded the captain stating, “look how high we are.” Inaddition, when one of the air traffic controllers handling the flight stated to the flight crew,“I’ve never seen you guys up at forty one there,” the captain replied, “we don’t have anypassengers on board so we decided to have a little fun and come on up here” and “this isactually our service ceiling.” The Safety Board concludes that the pilots’ aggressivepitch-up and yaw maneuvers during the ascent and their decision to operate the airplane atits maximum operating altitude (41,000 feet) were made for personal and not operationalreasons.

Pinnacle Airlines required that a climb to 41,000 feet be conducted at an airspeedof 250 knots (0.70 Mach).98 However, FDR data showed that the flight crew conductedthe climb from 37,000 to 41,000 feet at an airspeed that decreased from 203 knots(0.63 Mach) at the start of the climb to 163 knots (0.57 Mach) as the airplane leveled off at41,000 feet. FDR data also showed that the flight crew conducted the climb from 37,000to 41,000 feet with the autopilot vertical speed mode engaged and a commanded verticalspeed of 500 fpm. The airplane could not sustain the required airspeed while climbing at500 fpm, which resulted in the 40-knot loss of airspeed, and, once level at 41,000 feet, theairplane was operating in a “region of reversed command”99 in which available thrust wasnot sufficient to increase airspeed. The flight crew should have used the autopilot airspeedmode rather than the vertical speed mode to prevent the loss of airspeed. The SafetyBoard concludes that the flight crew’s inappropriate use of the vertical speed mode duringthe climb was a misuse of automation that allowed the airplane to reach 41,000 feet in acritically low energy state.

97 The pilots were experienced in the airplane, so the maneuvering would not have been the result ofimproper control inputs by a pilot who was unfamiliar with the airplane’s handling characteristics.

98 Specifically, the climb should be conducted at 250 knots until Mach 0.7 is reached, at which pointMach 0.7 becomes the primary indicator of airspeed.

99 Region of reversed command is also known as operating “on the back side of the power curve.” Itoccurs when the available engine thrust cannot overcome the increased induced drag associated with lowairspeed. As a result, the airplane cannot accelerate and may decelerate.


Statements on the CVR recording indicated that the pilots did not fully understandthe aerodynamic and performance considerations associated with operations at an altitudeof 41,000 feet. Specifically, about 2154:07, the captain stated, “we’re losing here. We’regonna be … coming down in a second here.” About 3 seconds later, the captain stated,“this thing ain’t gonna … hold altitude. Is it?” The first officer responded, “it can’t man.We … (cruised/greased) up here but it won’t stay.” About 2154:19, the captain stated,“yeah that’s funny we got up here it won’t stay up here.”100

Pinnacle Airlines’ ground school upset training addressed high altitudeaerodynamics, swept-wing design characteristics, and the use of performance charts. Also,the company’s ground school performance training provided pilots with instruction onhow to use climb capability charts to determine thrust settings for altitudes above36,000 feet. The CVR recording did not indicate whether the flight crew consulted thecompany’s altitude and climb ability charts before initiating the climb to 41,000 feet.However, the Safety Board concludes that the improper airspeed during the climbdemonstrated that the pilots did not understand how airspeed affects airplane performanceand did not realize the importance of conducting the climb according to the publishedclimb capability charts. Section 2.3.1 discusses high altitude training for regional jetoperations.

2.2.2 Aerodynamic Stall and Upset Event

Even though the pilots recognized that the airplane’s performance wasdeteriorating, neither pilot appeared to respond to this situation with urgency. The pilotscontacted the controller about 2154:32 and requested a lower altitude; however, during thetime that the controller was coordinating the descent, the airplane’s airspeed furtherdeteriorated to Mach 0.53 (150 knots), and the stickshaker activated for the first of fivetimes. Afterward, the stickshaker activated four times, and the stickpusher activated fourtimes, pushing the control column forward automatically.101 The flight crew responded tothe stickpusher each time by pulling back on the control column. These control columninputs caused the airplane’s pitch angle to increase to a maximum ANU value of 29º about2154:59, and then the airplane entered an aerodynamic stall. Afterward, the airplane’spitch angle decreased to a maximum AND value of 32º about 2155:06. While the pitchangle was decreasing, a left rolling motion began, which eventually reached 82º left wingdown, and the N1 and fuel flow indications for both engines declined steadily to zero,indicating that both engines had flamed out. The Safety Board concludes that the upsetevent exposed both engines to inlet airflow disruption conditions that led to engine stallsand a complete loss of engine power. The double engine failure is further discussed insection 2.2.3.

100 During postaccident interview, several company pilots stated that, even though they had been able toclimb the CRJ to 41,000 feet, the airplane was not able to stay at that altitude for an extended period becausethe airplane’s performance had deteriorated.

101 During the public hearing on this accident, a Bombardier engineer testified that the stickpusher hadfunctioned normally during the flight.


During the investigation, the aircraft performance group determined that thestickshaker was functioning normally102 but that the airspeed indicator’s low speed cuewas 10 knots low. As a result, at the time of stickshaker activation, the low speed cue wasindicating that the airplane’s speed was 10 knots above the stickshaker speed. Theerroneous information shown by the low speed cue resulted from a software error.103

According to Pinnacle Airlines, its flight crewmembers were taught that the top ofthe low speed cue indicated the airspeed at which the stickshaker would initially activate.However, the flight crews were also trained to respond to stickshaker activation,regardless of whether the airspeed was above the low speed cue, because the stickshaker isthe primary warning to pilots of an impending stall. In addition, when an airplane’s speedis about 10 knots from the top of the low speed cue, especially when operating at analtitude of 41,000 feet, pilots should realize that the airplane is dangerously close to animpending stall. When the stickshaker activated during the accident flight, the pilotsshould have immediately attempted to accelerate the airplane to a safe airspeed bydescending; sufficient reserve power was not available from the engines while the airplanewas at 41,000 feet. Thus, the accident pilots should have responded appropriately to thestickshaker and used the low speed cue only as a secondary indication showing that theairspeed was dangerously slow.

Even though the flight crew was eventually able to recover the airplane from theupset event, the flight control inputs made during the upset were opposite of what wasrequired to recover the airplane. FDR data showed that the flight crew moved the controlcolumn aft after the first stickpusher activation and that the crew moved the controlcolumn aft with increasing magnitude after the next three activations of the stickpusher.

A reason that might explain why the pilots made these flight control inputs, whichexacerbated the upset event, was that Pinnacle Airlines’ stall recognition and recoverysimulator training focused on recovery with a minimum loss of altitude (which is commonthroughout the aviation industry). As a result, the pilots were trained to apply power torestore the energy state of the airplane and to maintain altitude.104 In this accident, thepilots’ inputs could have been the result of their attempt to recover using a minimalaltitude loss recovery technique, and, as the repeated stall events occurred with increasingnose-down pitch attitude, the pilots could have been instinctively trying to arrest the

102 The Safety Board compared the AOA recorded on the FDR at the time of the stickshaker activationswith Bombardier’s stickshaker design criteria for the flight condition and determined that the stickshakeractivated at the expected AOA (about 7.8º) and airspeed (about 150 knots).

103 In December 2004, the FAA sent a letter to Transport Canada that recommended, among other things,that Bombardier change “the airspeed tape display software to more accurately depict the top of the LowSpeed Awareness (top of the red band) at all altitudes and Mach Numbers.” In February 2005, Bombardierindicated that it would include an appropriate design change the next time the stall protection computer andthe air data computer were modified and that, in the interim, its FCOM would be revised to providenecessary guidance material on changes to the computation required to determine the low speed cue. InNovember 2006, Bombardier stated that it had not yet scheduled the modification; in December 2006,Bombardier issued the revised FCOM.

104 The Safety Board could not determine whether the pilots applied power because the throttle leverangle parameter was not recorded on the FDR.


nose-down pitch moment or responding inappropriately to the stickpusher. The SafetyBoard concludes that the pilots’ lack of exposure to high altitude stall recovery techniquescontributed to their inappropriate flight control inputs during the upset event. Section 2.3.2discusses stall recognition and recovery training.

2.2.3 Double Engine Failure

About 2155:06, the flight crew declared an emergency and asked the controller tostand by. CVR evidence showed that the flight crew recognized the nature of theemergency; specifically, about 2155:23, one pilot stated to the other, “we don’t have anyengines.” However, the CVR also showed that the flight crew did not begin the first itemof the double engine failure checklist (which is a memory item) until 1 minute 19 secondsafter the statement on the CVR recording about the double engine failure. Also, FDR datashowed that the pilots did not achieve and maintain the target airspeed of 240 knots(another memory item on the checklist). Because the flight crew did not achieve thisairspeed, both engines’ cores had decelerated and stopped before the airplane descendedthrough an altitude of 28,000 feet.

The double engine failure checklist indicated that, between the altitudes of 21,000and 13,000 feet, the windmill restart procedure should be used to relight the engines. Thisprocedure required that the pitch attitude of the airplane be reduced to and maintained at-8º to accelerate the airplane to an airspeed of 300 knots or greater. However, the pitchinputs made by the flight crew were not of sufficient magnitude and were not sustained.As a result, the crew did not achieve the 300-knot or greater airspeed required for theprocedure; FDR data showed that the highest airspeed attained during the restart attemptwas 236 knots and that the engines’ N2 (core rotation) indications remained at zero. TheSafety Board concludes that the captain did not take the necessary steps to ensure that thefirst officer achieved the 300-knot or greater airspeed required for the windmill enginerestart procedure and then did not demonstrate command authority by taking control of theairplane and accelerating it to at least 300 knots. The Safety Board further concludes thatthe first officer’s limited experience in the airplane might have contributed to the failedwindmill restart attempt because he might have been reluctant to command the degree ofnose-down attitude that was required to increase the airplane’s airspeed to 300 knots.

Because the flight crewmembers were unsuccessful in their attempt to relight theengines using the windmill procedure, they elected to descend the airplane to an altitude of13,000 feet so that they could attempt to restart the engines with the APU. Once theairplane descended to an altitude of 13,000 feet, the flight crew attempted fourAPU-assisted engine restarts (two attempts per engine) during a 5-minute period (2207:04to 2212:07) and between the altitudes of about 12,900 and about 5,000 feet. FDR datashowed that the N2 indications for both engines remained at zero during the restartattempts. The Safety Board concludes that, despite their four APU-assisted engine restartattempts, the pilots were unable to restart the engines because their cores had locked.Without core rotation, recovery from the double engine failure was not possible.105

105 Section 2.2.3.1 discusses the flight crew’s performance of the double engine failure checklist.


The Safety Board considered whether engine hardware was a factor contributing tothe lack of core rotation. However, engine teardowns found no mechanical failures orevidence of any condition that would have prevented engine core rotation.

The Safety Board then considered whether an electrical or mechanical probleminterfered with the ability of the cores to achieve rotation. However, inspection and testingof the APU and other airplane start system components found no conditions that wouldhave prevented torque delivery to either engine during the four APU-assisted restartattempts. Also, FDR data showed that the LCV was open during these restart attempts,106

and testing showed that it was capable of providing pneumatic power from the APU tostart initial rotation in each engine. A systems simulation study (see section 1.16.4)showed that the LCV had likely opened by at least 18º during the flight, which shouldhave resulted in some detectable core rotation if the engine cores were capable of rotation.In addition, the change in engine oil temperatures107 showed that air was flowing throughthe ATS. This finding, along with the results of the airplane start system componenttesting, showed that the LCV was likely fully open.

The Safety Board considered whether the slight increases in core-driven hydraulicpump pressures shown on the FDR during the final minutes of the flight (as described insection 1.16.3) were evidence of engine core rotation. The airplane’s start system wasoperating normally during the restart attempts; thus, if the cores were free to rotate, theywould have quickly accelerated. As a result, the Board determined that the slight increasesin hydraulic pump pressures that were recorded on the FDR were not the result of enginecore rotation.

On the basis of the information discussed in section 1.18.2, the Safety Boardconcludes that the GE CF34-1 and CF34-3 engines had a history of failing to rotate duringin-flight restart attempts on airplanes undergoing production acceptance testing atBombardier. GE attributed the problem to interference contact at an air seal in the highpressure turbine and, along with Bombardier, referred to this condition as core lock. Thelack of core rotation on the accident airplane engines was similar to the instances of corelock experienced by CF34 engines during Bombardier’s acceptance testing, except thatthe accident airplane engines were exposed to more severe thermal distress than theengines on the production airplanes. Specifically, the accident airplane’s engines flamedout from high power and high altitude, whereas the engines installed on the productionairplanes were shut down only after their internal temperatures were stabilized.108

Flameouts at high power and high altitude produce even greater thermal distressbecause internal temperatures are the hottest at high power settings and the air is colder athigh altitudes. The increased thermal shock exacerbates the loss of component clearance

106 The FDR parameter for the LCV position shows that the valve is open once it reaches a position thatis greater than 4.8º from its normally closed position.

107 The FDR recorded a steady decline in engine oil temperature after the upset and showed that thissteady decline ceased at the time of the engine restart attempts.

108 On November 20, 2006, the Safety Board issued recommendations to the FAA to address this andother core lock-related issues; see sections 1.18.3.1 and 4.3 for information.


and alignment. Because the accident engines flamed out under these conditions, axialmisalignment caused the seal teeth, which were positioned aft of their normal operatinggrooves, to contact stationary abradable material when radial seal clearances closed down.Once core rotation stopped, binding prevented core rotation from resuming during thewindmill and APU-assisted restart attempts. No physical evidence of core lock was foundinside the engines because the thermally induced interference occurred after core rotationhad stopped and operating clearances were restored afterward as the engine cooled.

The Safety Board concludes that both engines experienced core lock because ofthe flameout from high power and high altitude, which resulted from the pilot-inducedextreme conditions to which the engines were exposed, and the pilots’ failure to achieveand maintain the target airspeed of 240 knots, which caused the engine cores to stoprotating; both of these factors were causal to this accident.

2.2.3.1 Performance of the Double Engine Failure Checklist

A critical error made by the flight crew while performing the double engine failurechecklist was failing to establish and maintain an airspeed of 240 knots before beginningthe procedures to restart the engines. During the public hearing on this accident, a GEmanager testified, “as long as core rotation is maintained, you will not have core lock …we have a body of data that shows that 240 knots maintains core rotation.”

Another critical error made by the flight crew was failing to increase the airspeedto at least 300 knots before beginning the windmill restart procedure. About 2159:16,when the FDR resumed operation after a loss of power lasting about 4 minutes, theairplane’s airspeed was 178 knots. About 2200:38, the captain told the first officer toincrease the airspeed to above 300 knots, and the first officer acknowledged thisinstruction. About 1 minute later, the captain again told the first officer to increase theairspeed to 300 knots. However, FDR data showed that the maximum airspeed achievedduring the procedure—236 knots—was achieved only briefly.

Other errors in the performance of the double engine failure checklist included thecaptain’s failure to call out the items using standard phraseology and indicate when thechecklist was complete. According to the simulator instructor who conducted part of thecaptain’s upgrade training, the captain did not always perform checklists according tocompany procedures.109 This reported behavior in the simulator was consistent with thecaptain’s performance of the double engine failure checklist. Specifically, although thechecklist procedures were clear, the captain did not effectively manage the execution ofthe checklist or ensure that the first officer had achieved the necessary airspeed, which isinconsistent with the basic tenets of CRM and basic airmanship.

109 As discussed in section 1.5.1, the instructor stated that the captain would, at times, misstate the statusof a checklist item, read a checklist item but not accomplish it, take action on an airplane system that was notthe one noted in the checklist, or see the appropriate checklist displayed in an EICAS message but still callfor the wrong checklist.


In addition to the captain’s previous difficulties in executing checklists, twoadditional factors likely played a role in the flight crew’s performance of the doubleengine failure checklist. The first factor was the stress associated with the situation. Thestress included changes to the cockpit environment, such as the reduced cockpit lightingand the increase in ambient noise associated with the deployment of the ADG. Anotherstressor was the instrumentation available to the captain during the 4-minute period inwhich the ADG was the sole source of power—from the right seat, he would not have hada primary flight display showing airspeed and altitude; thus, he would have had to lookover to the left side of the instrument panel or use the standby instruments in the center ofthe panel while performing the double engine failure checklist and other nonflying pilotduties. Also, the stress of the situation might have caused both pilots to experienceattentional tunneling, that is, the focusing of attention on a single task or portions of a task,which results in neglecting other critical tasks. For example, the captain did not recognizethat the airspeed required for N2 rotation (which was necessary for restarting the engines)had not been achieved. The second factor was that the pilots had only received groundschool instruction on the double engine failure checklist. Thus, it is possible that theywere executing it for the first time.

Even though maintaining an airspeed of 240 knots was a memory item on thechecklist, it is possible that the pilots did not realize the importance of this airspeed to thesuccess of the restart sequence. The Safety Board concludes that the importance ofmaintaining a minimum airspeed to keep the engine cores rotating was not communicatedto the pilots in airplane flight manuals. For example, at the time of the accident,Bombardier’s and Pinnacle Airlines’ double engine failure checklists stated that 240 knotswas the “target” airspeed for the procedure but did not indicate that this airspeed wasessential to the success of the restart procedure. As a result of the accident, Bombardierand Pinnacle Airlines revised their double engine failure checklist to indicate that240 knots was the “minimum” airspeed and that the failure to maintain positive corerotation might prevent a successful restart. It is also possible that, after the double enginefailure, the pilots were attempting to operate the airplane at its best glide speed of170 knots, which is 70 knots less than the speed needed to maintain engine core rotation.

The Safety Board examined whether the seat swap would have affected the pilots’performance during the double engine failure checklist.110 The captain, who wasresponsible for performing the checklist, had significant experience in the right seat of theairplane, so the position of the controls and switches would have been familiar to him.Further, the tasks that the captain was performing for the checklist were not well practicedbecause of the lack of training in this area (as discussed in section 2.3.3), so he would nothave developed any habit patterns or motor memory skills from the left seat that wouldhave interfered with his ability to perform from the right seat. The lack of a flight displayon the right side of the cockpit should not have affected the captain’s ability to recognizethat the required airspeeds had not been achieved because airspeed was clearly presentedon the standby instrument and the left-side primary flight display. The first officer was

110 It is not known which pilot suggested that the first officer sit in the captain’s seat during most of theaccident flight. However, both pilots demonstrated poor judgment in allowing the seat swap to occur.


responsible for flying the airplane, and the seat swap should not have affected his ability toachieve the commanded speeds. Thus, the pilots’ seat swap, although contrary to standardoperating practice, was not a factor that affected the pilots’ performance of the doubleengine failure checklist.111

The Safety Board concludes that the captain’s previous difficulties in checklistmanagement, the situational stress, and the lack of simulator training involving a doubleengine failure contributed to the flight crew’s errors in performing the double enginefailure checklist.

2.2.4 Communications With Air Traffic Controllers and Management of Forced Landing

About 2206:40, the controller (at the sector 53 position) asked the pilots whetherthey wanted to land. The captain, during his reply to the controller, failed to disclose thetrue nature of the emergency, stating, “just stand by right now we’re gonna start this otherengine and see … if everything is okay.” About 2209:06, the first officer informed thecontroller that the airplane was experiencing a double engine failure. This notificationhappened almost 14 minutes after the flight crew first recognized (according to CVRevidence) that a double engine failure had occurred. During that time, the flight crew hadnumerous opportunities to notify the controller of the double engine failure. For example,the controller (at the sector 30 position) had earlier asked the flight crew about the natureof the emergency, but the captain responded, “we had an engine failure up there … sowe’re gonna descend down now to start our other engine.” This controller then stated,“understand controlled flight on a single engine right now,” but the captain did not correctthis information by informing the controller of the actual situation. Thus, thetransmissions describing a loss of only one engine indicated that the captain intentionallyconveyed information to the controllers that did not represent his own understanding ofthe situation.

During postaccident interviews, company pilots stated that, if an emergencysituation (such as the loss of one or both engines) were to occur, they were instructed toprovide relevant information to air traffic controllers, as workload and conditions allowed,about the nature of the emergency and the assistance that was needed. By misleading thecontrollers about the true nature of the emergency, the captain lost the full use of avaluable resource in an emergency situation.112 For example, if the captain had notified thecontroller early in the descent about the double engine failure, the controller would havelikely provided the pilots with suggested vectors for a descent to and landing at an airportwithin the airplane’s best glide range.

111 About 2208:17, after the sound of oxygen mask use ceased, the CVR recorded the captain stating“switch,” indicating that the captain was preparing to return to the left seat and have the first officer return tothe right seat.

112 The captain’s inaccurate communications to the controllers about the loss of only one engine werealso inconsistent with the basic tenets of CRM.


The company’s double engine failure procedure stated that, if neither engine wasrestarted, the flight crew should consider a forced (emergency) landing. Five airports thatwere suitable for an emergency landing were located within 60 miles of the upset location(see section 1.16.1.3). However, the flight crew did not consider making an emergencylanding at any of these airports. Between the time that the flight crew first realized that adouble engine failure had occurred and the time that the captain notified the controller ofthe actual situation, the airplane had descended from 35,000 to 10,000 feet. When theairplane was at an altitude of 10,000 feet, only one airport (AIZ) was still within theairplane’s best glide range, but the pilots had already overflown that airport. At thataltitude, JEF was just outside the airplane’s best glide range.113 The aircraft performancestudy for this accident showed that drag produced by the 5.6º spoiler deployment had aminimal effect on the airplane’s ability to reach JEF.

A double engine failure in a two-engine airplane is an emergency situation thatrequires timely action to stabilize the situation and effective coordination of all availableresources and options to ensure a successful outcome. The flight crew’s failure to discussan emergency landing during most of the descent demonstrated the crew’s poor judgment.Also, the captain’s failure to inform the controllers about the true nature of the situationearly in the descent demonstrated the pilots’ apparent reluctance to have their deviationfrom standard operating procedures and their unprofessional behavior detected.

Multiple opportunities existed during the descent for the pilots to talk withcontrollers and between themselves about the need to make an emergency landing. Thepilots acted in a manner that was not consistent with ensuring safety of flight or effectivelymanaging an in-flight emergency. The Safety Board concludes that the pilots’ failure toprepare for an emergency landing in a timely manner, including communicating with airtraffic controllers immediately after the emergency about the loss of both engines and theavailability of landing sites, was a result of their intentional noncompliance with standardoperating procedures, and this failure was causal to the accident.

2.2.5 Accident Sequence Summary

This accident was not the result of a single action, decision, or mistake by theflight crew. Instead, the accident was the result of poorly performing pilots whointentionally deviated from standard operating procedures and basic airmanship. Also,CVR evidence showed that the pilots’ tone in the cockpit was unprofessional114 and thattheir attitude was inconsistent with the demands associated with, and the precisionrequired for, flying a high performance turbojet airplane.

113 On the basis of the airplane’s location at this point in the flight, the air traffic controller correctlydirected the airplane to JEF, which was essentially straight ahead along the airplane’s flightpath. If theairplane had been directed to AIZ, a 160º left turn would have been required, which would have cost theairplane altitude, airspeed, and distance.

114 As indicated in the CVR transcript in appendix B, the flight crew’s conversation was generallycasual, and sounds of joking and laughing were heard during the recording. Also, the transcript showed thatthe captain left his duty station unnecessarily to get a soft drink.


According to models of human error, the pilots’ performance during the climb andtheir decision to operate at 41,000 feet can be described as “optimizing violations,” whichoccur when someone disregards defined procedures intentionally to make a job moreinteresting or engaging, to push limits, or to impress another.115 For example, the pilots’CVR statements about operating at an altitude of 41,000 feet were consistent withthrill-seeking behavior. It is not possible to determine the specific reasons that the pilotsdemonstrated these optimizing violations. However, according to situational controltheory, the chance that someone will violate a rule increases when such a violation resultsin personal achievement and is likely to go undetected.116 In this case, the Part 91repositioning flight with no passengers or other crewmembers on board presented thepilots with an opportunity to reach personal milestones associated with aggressivemaneuvering and operating the airplane at its maximum operating altitude.

The Safety Board’s investigation of this accident did not reveal any evidence thatthe pilots had previously engaged in the unprofessional behavior demonstrated during theaccident flight. Also, the CVR recording contained no indication that the pilots anticipatedthe adverse outcome resulting from their intentional deviations from standard operatingprocedures. Such intentional deviations can compromise the margins of safety that are inplace as a result of procedures established by the company, the manufacturer, and theFAA. A consequence associated with compromising these margins of safety is that theoperator becomes more vulnerable to the catastrophic effects of unintentional errors.117

Evidence indicated that the critical human performance failures during the flightwere the result of intentional behavior and were not consistent with typical errors (slips,lapses, and mistakes) found in most flight crew-involved accidents involving Part 121operators. Although the pilots demonstrated some performance failures and deficienciesin basic airmanship that were consistent with the more typical errors found in accidents,such as their failure to achieve required airspeeds during the descent (see section 2.2.3),the pilots’ overall actions during the accident flight were not consistent with the degree ofdiscipline, maturity, and responsibility required of professional pilots. The Safety Boardconcludes that the pilots’ unprofessional operation of the flight was intentional and causalto this accident because the pilots’ actions led directly to the upset and their improperreaction to the resulting in-flight emergency exacerbated the situation to the point that theywere unable to recover the airplane.

The Safety Board is concerned about the willful misconduct demonstrated by thepilots during the accident flight. The Board has investigated other recent accidents inwhich pilots did not adhere to standard operating procedures and demonstrated a lack ofcockpit discipline. Section 2.4 discusses this problem and the need for broad industryaction involving pilots, operators, and the FAA to address the problem.

115 J.T. Reason, Human Error (New York: Cambridge University Press, 1990).116 D. Huntzinger, “Pilots Behaving Badly,” Vector (New Zealand: Civil Aviation Authority,

January/February 2001).117 P.T.W. Hudson, W.L.G. Verschuur, D. Parker, R. Lawton, and G. van der Graff, “Bending the Rules:

Managing Violation in the Workplace.” For more information about this paper, see<http://www.energyinst.org.uk/heartsandminds/docs/bending.pdf>.


2.3 Flight Crew Training

2.3.1 High Altitude Training

High altitude climbs were not practiced during Pinnacle Airlines’ simulatortraining. The circumstances of the accident flight and the actions taken by PinnacleAirlines and Bombardier after the accident to increase awareness of CRJ performancecapabilities and limitations during high altitude operations118 indicate that high altitudetraining at regional jet operators may not be adequate.

Regional airlines are typically the journeyman career step for professional pilotsseeking employment with major air carriers. Until the advent of the regional jet, pilots atregional airlines typically operated turboprop airplanes. Because turboprop airplanes donot have the performance capabilities of, or operate at the same speeds and flight levels as,a regional jet, it is possible that some regional airline pilots were not adequately trained tomake the transition to a turbojet airplane. Also, regional airline pilots with military flighttraining may have received more thorough high altitude training compared with civilianpilots; however, the number of regional airline pilots who had previously received militaryflight training has decreased since the 1980s.119

Because of advances in airplane equipment (turboprop to turbojet airplanes) atregional airlines and changes in the pilot force transitioning to regional jet operations, thecurrent training methods and syllabuses for high altitude training at these operators maybe in need of an industrywide revision. The Safety Board concludes that revised highaltitude training syllabuses for pilots who operate regional jet airplanes would help ensurethat these pilots possess a thorough understanding of the airplanes’ performancecapabilities, limitations, and high altitude aerodynamics. Therefore, the Safety Boardbelieves that the FAA should work with members of the aviation industry to enhance thetraining syllabuses for pilots conducting high altitude operations in regional jet airplanes.The syllabuses should include methods to ensure that these pilots possess a thoroughunderstanding of the airplanes’ performance capabilities, limitations, and high altitudeaerodynamics. The Safety Board further believes that the FAA should determine whetherthe changes to be made to the high altitude training syllabuses for regional jet airplanes, asrequested in Safety Recommendation A-07-1, would also enhance the high altitude

118 As previously stated, Bombardier issued an all operator message to remind pilots of the importanceof adhering to prescribed performance charts when operating at high altitudes and to inform them thatclimbing at a too-slow airspeed might result in performance deterioration once altitude is achieved. PinnacleAirlines revised its FCOM to limit the minimum climb speed above 10,000 feet to 250 knots/0.70 Mach,whichever was lower. The company also placed altitude and climb capability charts into the QuickReference Handbook for easy access during flight and issued guidance to pilots regarding the need to limitoperation of the airplane to 37,000 feet or below. In addition, the company’s ground training now includesadditional emphasis on these issues in the performance and high altitude training segments and ademonstration of these areas during simulator training.

119 During the 1980s, about 80 percent of the pilots hired by all commercial airlines had military flighttraining, but, according to the FAA in 2001, this number has decreased to about 40 percent.


training syllabuses for all other transport-category jet airplanes and, if so, require thatthese changes be incorporated into the syllabuses for those airplanes.

2.3.2 Stall Recognition and Recovery Training

The stall recognition and recovery training at Pinnacle Airlines, as well aselsewhere in the aviation industry, focuses on approach to stalls and recovery withminimum loss of altitude. Because most stalls occur when the airplane is maneuvering atlower altitudes,120 recoveries are practiced during training by applying power to restorethe energy state of the airplane and maintaining pitch. Although this strategy can beeffective at lower altitudes where the airplane has excess thrust, it is not effective when theairplane is at high altitudes, as demonstrated by the circumstances of this accident, orwhen a full stall has developed with resulting disruption of airflow to the engines, asdemonstrated by the circumstances of the 1996 ABX Air accident in Narrows, Virginia.121

After the accident, Pinnacle Airlines added to its simulator training a high altitudebuffet demonstration that emphasizes the need to get the airplane’s nose down to increaseairspeed when engine thrust is marginal. Also, Bombardier’s all operator message thatwas issued after the accident stated, in part, the following: “in the event that a stickshaker/approach to stall occurs, the crew should expect that a deliberate loss of altitudewill likely be required to restore the aircraft to a normal energy state and to prevent anaerodynamic stall and possible departure from controlled flight.” The Safety Boardconcludes that, because most training for stalls occurs with the airplane at low altitudes,the training methods may introduce a bias in stall recovery techniques by encouragingpilots to minimize altitude loss and not fully recognizing other available recoverytechniques. Therefore, the Safety Board believes that the FAA should require that aircarriers provide their pilots with opportunities to practice high altitude stall recoverytechniques in the simulator during which time the pilots demonstrate their ability toidentify and execute the appropriate recovery technique.

Another factor that might have contributed to the improper control inputs duringthe stall event was the flight crew’s unfamiliarity with the stickpusher system on thisairplane. The crew would have been exposed to stickpusher activation during systemstraining and the first-flight-of-the-day operational checks of the system, and, in the case ofthe accident flight, the crew experienced the system’s activation during one of the pitch-upmaneuvers made during the climb. However, it is unclear the extent to which either pilot

120 At the time of the accident, Pinnacle Airlines conducted its stall recognition and recovery simulatortraining at an altitude of 10,000 feet.

121 During that accident investigation, the Safety Board found that the flying pilot applied inappropriatecontrol column back pressure during the stall recovery attempt and that his performance of the stall recoveryprocedure, which was established in the company’s operations manual, was inadequate. In its final report onthe accident, the Safety Board stated that the probable causes included “the inappropriate control inputsapplied by the flying pilot during a stall recovery attempt” and “the failure of the nonflyingpilot-in-command to recognize, address, and correct these inappropriate control inputs.” For moreinformation, see National Transportation Safety Board, Uncontrolled Flight Into Terrain, ABX Air (AirborneExpress), Douglas DC-8-63, N827AX, Narrows, Virginia, December 22, 1996, Aircraft Accident ReportNTSB/AAR-97/05 (Washington, DC: NTSB, 1997).


had experience with the stickpusher system during simulator training because the industrystandard for stall training was to initiate recovery at the onset of the stickshaker, which,during a proper recovery, would preclude stickpusher activation.

During the Safety Board’s public hearing on this accident, a Bombardier trainingpilot testified that he had seen pilots during training respond incorrectly to stickpusheractivation because “they are scared, and they don’t know what to do [or] how to react.”He added, “proper training is a huge factor, to make sure that if you end up on a pusher,this is what you need to do.”

The Safety Board acknowledges that additional training may be required toimprove pilot response to stickpusher activation. However, current training protocols andFAA standards train pilots to initiate stall recovery before stickpusher activation. As aresult, there may be unintended consequences and negative transfer associated with theinclusion of stickpusher training into simulator training protocols without careful anddeliberate study. Because of these concerns, the Safety Board concludes that additionaltraining might improve pilot response to stickpusher activation, but such training, if notprovided correctly, could have an adverse impact on existing stall recognition andrecovery protocols. Therefore, the Safety Board believes that the FAA should convene amultidisciplinary panel of operational, training, and human factors specialists to study andsubmit a report on methods to improve flight crew familiarity with and response tostickpusher systems and, if warranted, establish training requirements forstickpusher-equipped airplanes based on the findings of this panel.

2.3.3 Double Engine Failure Training

At the time of the accident, double engine failure scenarios were not practicedduring Pinnacle Airlines’ simulator training. After the accident, the company incorporateda double engine failure scenario into its simulator training syllabus. During this scenario,a double engine failure occurs at an altitude of 35,000 feet, and flight crews are required touse the windmill restart procedure to relight the engines. The Pinnacle Airlines CRJprogram manager stated that this scenario would help familiarize the crew with theemergency power-only procedures and the effects of an ADG deployment.

Also, in May 2005, Pinnacle Airlines made changes to its double engine failurechecklist based on the changes made by Bombardier earlier that month. These changeshighlighted the airspeeds required for the procedure. For example, the revised checkliststated that a minimum (rather than target) airspeed of 240 knots must be maintained untilthe pilot was ready to restart the engines. Also, the changes indicated that 300 knots orgreater was required to achieve a sufficient N2 for the windmill restart and that thisairspeed must be maintained until at least one engine was restarted or restart attempts wereabandoned. Further, the revised checklist recognized the need to sacrifice altitude forairspeed by indicating that the 5,000-foot altitude loss that could be expected whenaccelerating from 240 to 300 knots might require pitch attitudes of 10º AND and thatpilots should start accelerating to achieve 300 knots at an altitude of 21,000 feet.


In addition, Pinnacle Airlines’ revised double engine failure checklist placed thefollowing information in a box labeled “CAUTION”: “failure to maintain positive N2 maypreclude a successful relight. If required, increase airspeed to maintain N2 indication.”According to the FAA’s guidance on checklist design,122 a caution is defined as “aninstruction concerning a hazard that if ignored could result in damage to an aircraftcomponent or system – which would make continued safe flight improbable.” The FAA’sguidance defines a warning as “an instruction about a hazard that, if ignored, could resultin injury, loss of aircraft control, or loss of life.” Because of the circumstances of thisaccident, the Safety Board questions the appropriateness of placing information about theconsequences of not maintaining positive N2 into a cautionary note when the FAA’sdefinitions suggest that a warning box would be a more appropriate transmission of thatinformation to pilots.

Pinnacle Airlines’ revised simulator training provides company pilots with anopportunity to reinforce the knowledge they obtained in ground school on the doubleengine failure checklist items, and the company’s revised checklist generally highlightsthe information that is necessary for pilots to successfully perform the double enginefailure procedure. The Safety Board concludes that some of the changes made byPinnacle Airlines to its double engine failure training and checklist guidance wouldbenefit pilots at other air carriers that operate the CRJ because such training wouldprovide pilots with the opportunity to practice double engine failure restart procedures inthe simulator and the guidance would ensure that pilots were aware of the minimumairspeeds needed during the procedures. Therefore, the Safety Board believes that theFAA should verify that all CRJ operators incorporate guidance in their double enginefailure checklist that clearly states the airspeeds required during the procedure and requirethe operators to provide pilots with simulator training on executing this checklist.

2.4 Flight Crew Professionalism

2.4.1 Part 91 Operations

As stated in section 2.2.5, the accident flight, a Part 91 repositioning flight with nopassengers or other crewmembers on board, presented the pilots with an opportunity toaggressively maneuver the airplane and operate it at the CRJ maximum operating altitude.Section 2.2.5 also noted that these behaviors were examples of optimizing violations,which occur when someone disregards defined procedures intentionally to make a jobmore interesting or engaging, to push limits, or to impress another. Although PinnacleAirlines had protections in place for minimizing errors and unprofessional behaviorduring line operations,123 the company did not have effective protections in place forpreventing optimizing violations during Part 91 operations. For example, even though the

122 Federal Aviation Administration, Human Performance Considerations in the Use and Design ofAircraft Checklists (Washington, DC: FAA, 1995).

123 These protections included pilot selection criteria, pilot training, company policies and procedures,and pilot oversight (line checks and pilot reports).


accident pilots were generally described favorably by instructors, check airmen, and otherpilots,124 the FAA’s operations supervisor of the Memphis FSDO stated, during the SafetyBoard’s public hearing on the accident, that, before this accident, “we had no idea thatanybody would ever switch seats during a flight and not operate in accordance with thestandard operating procedures for the company.”125

After the accident, Pinnacle Airlines began to review FDR data for all nonrevenueflights.126 The company’s decision to examine FDR data from these flights directlyaddressed the vulnerability of these operations to optimizing violations. During the SafetyBoard’s public hearing for this accident, the company’s chief pilot stated that the review ofFDR data would serve as oversight for Part 91 flights because “the pilots will know thatthey’re being monitored.” Also, the company’s vice president of safety and regulatorycompliance testified, “we want to make sure the aircraft is being operated in non-revenueoperations exactly the way it’s being operated in [Part] 121 operations.”

During the investigation of this accident, a management pilot from anothercompany with a CRJ fleet stated that “repositioning flights seemed to bring out the worstin their company’s pilots.” This pilot also stated that a review of FDR data from hiscompany’s repositioning flights showed that high bank angles and steep descents occurredoften and that pilots were taking the opportunity to perform excessive maneuvers that theycould not perform with passengers on board.

The Safety Board investigated an April 1993 accident in which an airplaneoperated by two GP Express Airlines pilots (with no passengers or other crewmembersaboard) crashed during a Part 91 training flight while the pilots were attempting to executea prohibited aerobatic maneuver at night. The Board determined that the probable causesof that accident included the pilots’ deliberate disregard for company and Federal

124 There were a few exceptions to these favorable comments. For example, the simulator instructorwho conducted part of the captain’s upgrade training stated that, in addition to the captain’s problemsperforming checklists in accordance with company procedures (as discussed in section 2.2.3.1), his biggestweaknesses were his critical decision-making and judgment. Also, the first officer was described as averageby the captain who flew with him during his last trip before the accident flight.

125 The Safety Board notes that, during the investigation of the January 1983 takeoff accident at DTWinvolving United Airlines flight 2885 (a cargo flight), the Board determined that the second officer hadoccupied the seat of the first officer and conducted the takeoff. The Board also determined that, on the basisof postaccident interviews with United Airlines pilots, seat swapping was not a prevalent practice at theairline. In its final report on this accident, the Board stated its concern about the flight crew’s “disregard offederal and company rules and regulations.” The Board determined that the probable cause of the accidentincluded the flight crew’s failure to follow procedural checklist requirements. Contributing to the cause ofthe accident was the captain’s decision to allow the second officer, who was not qualified to act as a pilot, tooccupy the seat of the first officer and to conduct the takeoff. For more information, see NationalTransportation Safety Board, United Airlines Flight 2885, Detroit, Michigan, January 11, 1983, N8053U,McDonnell Douglas DC-8-54F, Aircraft Accident Report NTSB/AAR-83/07 (Washington, DC: NTSB,1983).

126 In October 2006, Pinnacle Airlines stated that it was sampling random Part 91 flights and that areview of these data showed no abnormalities associated with these flights.


procedures and the company’s failure to instill in their pilots professionalism that isconsistent with the highest levels of safety.127

The circumstances of the Pinnacle Airlines and the GP Express Airlines accidentsand the statements of a management pilot from another company with a CRJ fleetdemonstrate the opportunity for pilots to behave unprofessionally during Part 91operations that are conducted without passengers or other crewmembers. Even whenprotections are in place to mitigate risks during regional airline operations, unprofessionalbehavior by pilots during Part 91 flights still occurs for multiple reasons, including theperception of a low risk of detection.

The airplanes used by regional airlines are lighter, smaller, and more agile thanthose used by larger air carrier operators, which may increase the potential forunprofessional behavior during Part 91 flights. For regional operators that have the abilityto download FDR data, routine monitoring of Part 91 flights can be an effective method toensure that the flights are conducted according to standard operating procedures. Forthose operators that do not have the ability to review FDR data from Part 91 flights,alternative methods to mitigate risk include specific guidance to pilots on the expectationsof performance for these flights and additional oversight for flight crews conducting theflights.

The Safety Board concludes that more scrutiny of regional air carrier pilots duringnonrevenue flights would minimize the opportunity for unprofessional behavior to occur.Therefore, the Safety Board believes that the FAA should require regional air carriersoperating under 14 CFR Part 121 to provide specific guidance on expectations forprofessional conduct to pilots who operate nonrevenue flights. The Safety Board furtherbelieves that, for those regional air carriers operating under 14 CFR Part 121 that have thecapability to review FDR data, the FAA should require that the air carriers review FDRdata from nonrevenue flights to verify that the flights are being conducted according tostandard operating procedures.

2.4.2 Industrywide Issues

In addition to the Pinnacle Airlines accident, the Safety Board has investigatedrecent accidents involving the lack of cockpit discipline and adherence to standardoperating procedures. These accidents include the following:

• Corporate Airlines flight 5966, Kirksville, Missouri, October 19, 2004. Theflight crew did not follow established procedures for a nonprecision approachat night in instrument meteorological conditions, did not adhere to the

127 National Transportation Safety Board, Controlled Flight Into Terrain, GP Express Airlines, Inc.,N115GP, Beechcraft C-99, Shelton, Nebraska, April 28, 1993, Aircraft Accident Report NTSB/AAR-94/01SUM (Washington, DC: NTSB, 1994).


established division of duties between the flying and nonflying pilot, and didnot adhere to the sterile cockpit rule.128

• Air Tahoma flight 185, Covington, Kentucky, August 13, 2004. The captaindid not follow crossfeed procedures for balancing the fuel in the airplane’s fueltanks, which led to fuel starvation in the left tank.129

• Executive Airlines flight 5401, San Juan, Puerto Rico, May 9, 2004. Thecaptain failed to execute proper techniques to recover from bounced landingsand failed to execute a go-around.130

• Aviation Charter King Air A100, Eveleth, Minnesota, October 25, 2002. Theflight crew was not adhering to company approach procedures and was noteffectively applying CRM techniques during the approach segment of theflight.131

• Federal Express Flight 1478, Tallahassee, Florida, July 26, 2002. The flightcrew failed to adhere to company procedures for flying and monitoring astabilized approach.132

Pilots and operators have responsibility for a flight crew’s cockpit discipline andadherence to standard operating procedures, as discussed in sections 2.4.2.1 and 2.4.2.2.

2.4.2.1 Pilot Responsibilities

The Safety Board has long been concerned about issues of crew professionalismand adherence to standard operating procedures. For example, on October 8, 1974, as aresult of several fatal air carrier accidents involving pilot performance (as described insection 1.18.3.2), the Board issued Safety Recommendation A-74-85, which asked theFAA to initiate a movement among pilot associations to form new, and regenerate old,professional standards committees to promote crew discipline and professionalism. (TheSafety Board classified Safety Recommendation A-74-85 “Closed—Acceptable Action”on March 10, 1977.)

128 In its final report on this accident, the Safety Board concluded that the pilots’ nonessentialconversation below 10,000 feet msl “was contrary to established sterile cockpit regulations and reflected ademeanor and cockpit environment that fostered deviation from established standard procedures, crewresource management discipline, division of duties, and professionalism, reducing the margin of safety wellbelow acceptable limits during the accident approach and likely contributing to the pilots’ degradedperformance.” For more information, see NTSB/AAR-06/01.

129 National Transportation Safety Board, Crash During Approach to Landing, Air Tahoma, Inc.,Flight 185, Convair 580, N586P, Covington, Kentucky, August 13, 2004, Aircraft Accident ReportNTSB/AAR-06/03 (Washington, DC: NTSB, 2006).

130 National Transportation Safety Board, Crash During Landing, Executive Airlines (doing business asAmerican Eagle) Flight 5401, Avions de Transport Regional 72-212, N438AT, San Juan, Puerto Rico,May 9, 2004, Aircraft Accident Report NTSB/AAR-05/02 (Washington, DC: NTSB, 2005).

131 National Transportation Safety Board, Loss of Control and Impact With Terrain, Aviation Charter,Inc., Raytheon (Beechcraft) King Air A100, N41BE, Eveleth, Minnesota, October 25, 2002, AircraftAccident Report NTSB/AAR-03/03 (Washington, DC: NTSB, 2003).

132 National Transportation Safety Board, Collision With Trees on Final Approach, Federal ExpressFlight 1478, Boeing 727-232, N497FE, Tallahassee, Florida, July 26, 2002, Aircraft Accident ReportNTSB/AAR-04/02 (Washington DC: NTSB, 2004).


Most pilot unions have professional standards committees, which are peerconsultation programs that are designed to, among other things, provide counseling andsupport to pilots who have demonstrated behavior that might adversely affect their abilityto perform their duties in a professional manner. Trained volunteer pilots who aremembers of these committees provide peer support, counseling, intervention, andmediation to pilots at the airlines that the unions represent. Airline pilots can seek theseservices on their own, or they can be referred to the professional standards committee by,for example, company managers who have become aware of a potential problem.

Pilot union professional standards committees appear to be an effective structure tohelp promote and ensure professionalism among pilots. However, not all air carrier pilotshave access to these professional standards committees. For those pilots without suchaccess, communications about the importance of professionalism can be delivered throughcompany and FAA personnel.

It is clear, on the basis of the overall safety and reliability of the National AirspaceSystem, that most pilots conduct operations with a high degree of professionalism.Nevertheless, a problem still exists in the aviation industry with some pilots actingunprofessionally and not adhering to standard operating procedures, as demonstrated bythe recent accidents investigated by the Safety Board that are cited in section 2.4.2.

After a series of six accidents between October and November 2004, the FAAissued Notice N8000.296, “Pilot Judgment and Decisionmaking” (see section 1.18.4). Thenotice, among other things, highlighted the pilot’s role in ensuring safety of flight.Specifically, the notice recommended that individual pilots examine their owndecision-making habits in terms of professionalism, thoroughness of preparation, andadherence to standard operating procedures. The FAA stated that it has since incorporatedsoft skills into Part 121 CRM training requirements and that a rewrite of FAAOrder 8400.10, Air Transportation Operations Inspector’s Handbook, would emphasizesoft skills.

Pilots are ultimately responsible for safely conducting a flight and for recognizingthe importance of adhering to standard operating procedures and acting professionally.Although broad, systemwide interventions can be applied to help address the problem ofpilots not adhering to standard operating procedures or acting unprofessionally, the mostdirect intervention is to address any deficiencies in these areas at the level of the pilot.Because pilot unions have expertise in safety, training, and operations and have a vestedinterest in advancing professional standards among the pilots they represent, these groupsare well positioned to take a leadership role to establish new educational approaches forreinforcing professionalism in the aviation industry. The Safety Board concludes thatproviding additional education to pilots on the importance of professionalism could helpreduce the instances of pilots not maintaining cockpit discipline or not adhering tostandard operating procedures. Therefore, the Safety Board believes that the FAA shouldwork with pilot associations to develop a specific program of education for all air carrierpilots that addresses professional standards and their role in ensuring safety of flight. Theprogram should include associated guidance information and references to recent


accidents involving pilots acting unprofessionally or not following standard operatingprocedures.

2.4.2.2 Operator Responsibilities

Operators also are responsible for monitoring their pilots’ adherence to standardoperating procedures and reinforcing expectations for professional standards of behavior.Operators have traditionally identified nonstandard performance in line operations duringcheckrides or line observations conducted by company check airmen or managementpersonnel. A problem with this method of oversight is that pilots might performdifferently during a checkride or a line observation because of the presence of a companycheck airman in the cockpit.

To help evaluate pilot performance during line operations, air carriers canimplement voluntary safety programs, such as the FOQA program. This program isespecially well suited for detecting exceedances that may occur during flight, such as highbank angles and unstabilized approaches, and assessing whether crews are conductingflights according to standard operating procedures. However, the FOQA program requiresequipment and support structures that some air carriers may not be able to maintain, suchas the capability to download FDR data. According to the FAA, as of November 2006,18 air carriers operating under Part 121 had implemented approved FOQA programs.

Another FAA-approved, voluntary safety program is the Aviation Safety ActionProgram (ASAP). This program encourages pilots to report safety concerns in anonpunitive environment, which allows the air carrier and the FAA to act on thisinformation before an accident or an incident occurs.133 Although an ASAP does not havethe technical requirements associated with a FOQA program, an ASAP depends on thewillingness of pilots to voluntarily submit reports about other pilots or themselves. TheFAA stated that, as of November 2006, it had accepted 51 ASAP memorandums ofunderstanding for pilots.134 (Of these ASAP memorandums of understanding, 49 were forPart 121 operators, and 2 were for Part 135 operators.)

In addition to the FOQA program and the ASAP, operators can assess pilotperformance during line operations with the Line Operations Safety Audit (LOSA), whichwas developed in 1994 through FAA-sponsored research, known as the Human FactorsResearch Project, at the University of Texas at Austin.135 The LOSA program is anobservational process that assesses CRM practices, the management of threats to safety,and human error during flight operations. Trained personnel associated with the projectconduct line observations under conditions of confidentiality so that the operator isprovided only with details of the observations and no information about the pilots who

133 At the time of the June 2005 public hearing, Pinnacle Airlines had committed to establishing anASAP for its pilots. In October 2006, the company reported that it was operating an FAA-approved ASAPfor its pilots.

134 The ASAP also includes dispatchers, flight attendants, and mechanics. Pinnacle Airlines reportedthat it planned to expand its ASAP to the company’s maintenance department during 2007.

135 For more information, see <http://homepage.psy.utexas.edu/homepage/group/HelmreichLAB>.


were involved. As a result, in contrast to a company line check, LOSA observations donot result in adverse actions against pilots who did not perform well during theirobservation.

LOSA methodology is well suited to assess the soft skills used by air carrier pilots(see section 1.18.4), and the observations can be used to identify intentional deviationsfrom standard operating procedures or prescribed rules and allow the operator to identifyreasons for these deviations. Notably, LOSA can address and document these issues to agreater extent than the FOQA program or the ASAP because, as previously stated, FOQAprograms require the capability to download FDR data and an ASAP requires thewillingness of pilots to submit reports about fellow pilots or themselves.136 Also, LOSAobservations have identified rule violations and deviations from procedures, whichsuggests that the pilots being observed do not view the LOSA observers as a threat (asthey might view company check airmen) and would be likely to perform in the samemanner as they would without an observer present.

After the accident, and as a result of a high initial failure rate for upgradingcaptains before the accident (see section 1.17.1.6), Pinnacle Airlines made severalchanges to its training program to address professionalism. These changes includedincreasing the minimum number of hours (from 10 to 25) that are required for upgradeoperational experience, restructuring CRM training to provide additional focus ondecision-making and the need to adhere to standard operating procedures, and placingadditional emphasis on leadership during upgrade training. However, the effectiveness ofthese changes in increasing professionalism, leadership, and adherence to standardoperating procedures would be difficult to evaluate fully without LOSA observations.137

On April 27, 2006, the FAA issued Advisory Circular (AC) 120-90, LineOperations Safety Audits. The AC provides the rationale and procedures for conducting aLOSA observation at an air carrier and explains that the program is distinct from, butcomplementary to, the FOQA program and the ASAP. By incorporating LOSAobservations into their internal oversight programs, Part 121 air carriers would haveanother method to monitor their pilots’ adherence to standard operating procedures andstandards of professionalism. The Safety Board concludes that LOSA observations canprovide operators with increased knowledge about the behavior demonstrated by pilotsduring line operations. Therefore, the Safety Board believes that the FAA should requirethat all 14 CFR Part 121 operators incorporate into their oversight programs periodicLOSA observations and methods to address and correct findings resulting from theseobservations.

In addition to the need for air carriers to incorporate LOSA observations into theiroversight methods, air carriers need to ensure safety through a formalized system safety

136 Despite these issues, the Safety Board recognizes that the FOQA program and the ASAP provide aircarriers with valuable information about the quality of their operations.

137 The LOSA program samples all activities in normal operations, whereas the FOQA program and theASAP rely on outcomes (flight parameter exceedances and adverse pilot-reported events, respectively) togenerate data.


process. One such process is a safety management system (SMS) program, whichincorporates proactive safety methods for air carriers to identify hazards, mitigate risk,and monitor the extent that the carriers are meeting their objectives. Program componentsinclude safety policy, safety risk management, safety assurance, and safety promotion.Tools such as the FOQA, ASAP, and LOSA programs are relevant to the safety assurancecomponent of an SMS program because they provide a direct means for air carriers toevaluate the quality of their training and operations. These tools can also be used in thesafety risk management component of an SMS program because they can help uncoverhazards to system operation.

SMS program initiatives have been developed in the international aviationindustry. For example, the European Joint Aviation Authorities recommend, but do notrequire, air carriers to establish an SMS program. Also, in June 2005, Transport Canadapassed regulations requiring that air carriers operating under Canadian AviationRegulations Part 705 (Part 121 equivalent) fully implement an approved SMS program bySeptember 2008. In addition, International Civil Aviation Organization (ICAO) Annex 6,“Operation of Aircraft,” states the following: “from January 1, 2009, [Member] Statesshall require, as part of their safety program, that an operator implements a safetymanagement system acceptable to the State of the Operator that, at a minimum:(a) identifies safety hazards; (b) ensures that remedial action necessary to maintain anacceptable level of safety is implemented; (c) provides for continuous monitoring andregular assessment of the safety level achieved; and (d) aims to make continuousimprovement to the overall level of safety.”138

In June 2006, the FAA published AC 120-92, “Introduction to Safety ManagementSystems for Air Operators.” The AC provides guidance for SMS program developmentfor air carriers and others in the aviation industry. The guidance was based on the FAA’sreview of existing SMS programs worldwide, its own internal SMS programs, and othersystem safety approaches. An appendix to the AC contains a listing of functionalrequirements for operators to use as minimum standards when creating an SMS program.

During a December 14, 2006, briefing to the Safety Board, the FAA stated that itintended to comply with the ICAO requirement for Member States to require thatoperators implement an SMS program by January 1, 2009. A rulemaking project team hasbeen formed, and the rulemaking project team leader stated that the team’s first meetingwas held in December 2006. In addition to these initial rulemaking activities, the FAAstated that it planned to initiate a series of SMS proof-of-concept trials in late 2007.During these trials, the FAA intends to work with a few operators that have voluntarilyimplemented SMS to gather the data needed for additional guidance material and tosupport the agency’s rulemaking efforts. The Board is encouraged by the FAA’s initialactivities to implement an SMS program. However, until the FAA issues a notice ofproposed rulemaking, the Board cannot fully evaluate whether the FAA will meet ICAO’sminimum requirements for an SMS program.

138 In November 2005, ICAO asked Member States to provide the organization with information aboutthe development of SMS programs. During 2006, ICAO published a safety management manual thataddressed concepts and processes required to implement an SMS program.


Historically, the FAA’s approach to its oversight of air carriers has emphasizedsurveillance to ensure regulatory compliance. However, in 1998, the FAA established theAir Transportation Oversight System (ATOS), a systems safety approach to air carrieroversight. The ATOS program was initially deployed at the 10 largest U.S. air carriers.The benefits of the ATOS program’s system safety approach to air carrier oversight,compared with the oversight conducted as part of the National Work ProgramGuidelines,139 include a more integrated approach to oversight that better identifies risksto system safety and a more effective allocation of oversight resources to problem areas.140

The Safety Board has previously expressed concerns about the ATOS program. Inits March 12, 2001, letter to the FAA about Safety Recommendation A-98-51,141 theBoard stated its concern that the FAA had not addressed how the ATOS program wouldensure that systemic problems were identified and corrected before they resulted in anaccident. As a result, the Board classified Safety Recommendation A-98-51 “Open—Unacceptable Response.” Also, in its report on the Alaska Airlines accident, the Boardaddressed its concerns about ATOS implementation and the program’s ability to detectproblem areas.142

Other concerns about the FAA’s implementation of ATOS have been noted. Forexample, according to a Government Accountability Office (GAO) report,143 the FAA’sATOS transition plan, dated March 1, 2004, did not set dates beyond fiscal year 2005 formoving additional air carriers to the ATOS program, and, as of September 2005, 15 aircarriers were under the ATOS program. Also, the GAO testified in November 2005 thatthe National Work Program Guidelines were still being used at those passenger airlinesthat were not covered under ATOS.144

The FAA acknowledged that staffing and budgetary resources were affectingATOS deployment. During October 2005, the FAA initiated its System Approach forSafety Oversight CFR Part 121 Pilot Project. The objectives of the project are to reviseATOS so that the program can handle all Part 121 air carriers; provide new policies,processes, and tools for measuring safety; and roll out the latest version of the ATOSprogram to all Part 121 air carriers by December 31, 2007.145 The FAA stated that

139 The National Work Program Guidelines are part of a traditional inspection program to ensure thatairlines comply with safety regulations. The guidelines have been in effect since 1985.

140 To apply some benefits of the system safety approach used in the ATOS program to those air carriersthat were not covered by ATOS, the FAA deployed the Surveillance and Evaluation Program during 2002 toaugment the oversight conducted as part of the National Work Program Guidelines.

141 This recommendation, which was issued as a result of the Safety Board’s investigation of theAugust 7, 1997, Fine Airlines flight 101 accident, can be found on the Board’s Web site.

142 National Transportation Safety Board, Loss of Control and Impact With Pacific Ocean, AlaskaAirlines Flight 261, McDonnell Douglas MD-83, N963AS, About 2.7 Miles North of Anacapa Island,California, January 31, 2000, Aircraft Accident Report NTSB/AAR-02/01 (Washington, DC: NTSB, 2002).

143 Government Accountability Office, Aviation Safety: System Safety Approach Needs FurtherIntegration Into FAA’s Oversight of Airlines, GAO-05-726 (Washington, DC: GAO, 2005)

144 Government Accountability Office, Aviation Safety: FAA’s Safety Oversight System Is Effective butCould Benefit From Better Evaluation of Its Programs’ Performance, GAO-06-266T (Washington, DC:GAO, 2005).


preparations were underway to keep this transition on schedule. Even if this project iscompleted according to its intended timetable, it will still take time to determine whetherATOS is an effective oversight method.

The Safety Board is concerned about the delay in deploying ATOS to additionalPart 121 air carriers because they are not receiving the benefits of a system safetyapproach to oversight.146 Although the ATOS and SMS programs are complementary andare designed to work in an integrated manner, an air carrier does not need to be underATOS oversight to effectively develop its own SMS program. The FAA’s initial guidancein AC 120-92 should facilitate the process of developing and implementing an SMSprogram. Existing voluntary system safety tools, such as the FOQA, ASAP, and LOSAprograms, have demonstrated their effectiveness in monitoring flight operations and areconsidered integral safety assurance components to an SMS program, but these programsdo not have universal application in the aviation industry. The Safety Board concludesthat all air carriers would benefit from SMS programs because they would require thecarriers to incorporate formal system safety methods into the carriers’ internal oversightprograms. Therefore, the Safety Board believes that the FAA should require that all14 CFR Part 121 operators establish SMS programs.

The Safety Board acknowledges that it may take time for the FAA to completeSMS rulemaking and for air carrier SMS programs to become fully operational. In itsreview of air carriers with FOQA programs at the end of 2006, the Board found that,besides Pinnacle Airlines, only one other regional air carrier had a FOQA program. (TheBoard is aware of at least one other regional air carrier that is working towardimplementing a FOQA program.) Although system safety tools such as FOQA and ASAPhave demonstrated safety benefits, the Board is concerned that these programs are notused more widely by regional air carriers. Because of the limited number of regional aircarriers in the lists of approved ASAP and FOQA programs, the Safety Board concludesthat the establishment of an ASAP and a FOQA program at regional air carriers wouldprovide the carriers with a means to evaluate the quality of their operations. Therefore, theSafety Board believes that the FAA should strongly encourage and assist all regional aircarriers operating under 14 CFR Part 121 to implement an approved ASAP and anapproved FOQA program.

145 For more information, see System Approach for Safety Oversight Program Update, datedJuly 7, 2006, at <http://www.faa.gov/safety/programs_initiatives/oversight/saso/update>. Also, inDecember 2006, the FAA stated that 46 air carriers operating under Part 121 were under the ATOS program.

146 The Safety Board notes that some air carriers that are not covered under ATOS, including PinnacleAirlines, have begun using ATOS job aids and inspection guidelines generated for FAA inspectors in theirown internal audit programs.


2.5 Quality of Flight Data Recorder Data for RegionalJet Airplanes

On May 16, 2003, the Safety Board issued Safety Recommendation A-03-15 to theFAA because of problems with the quality of FDR data recorded by several regional jetairplanes. Safety Recommendation A-03-15 asked the FAA to do the following:

Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, CanadairChallenger CL-600, and Fairchild Dornier 328-300 airplanes[147] be modified witha digital flight data recorder system that meets the sampling rate, range, andaccuracy requirements specified in 14 Code of Federal Regulations Part 121.344,Appendix M.

On June 9, 2005, the FAA stated that Embraer had released an SB to correct knownFDR anomalies on the Embraer 145 and 135 and that the Brazilian Department of CivilAviation issued an AD that required incorporation of the Embraer SB within 18 months.The FAA also stated that it planned to release a corresponding AD. In addition, the FAAstated that it was working with Transport Canada to get expeditious action fromBombardier regarding the problem of low update rates on the normal acceleration andpitch attitude parameters for Canadair CL-600-2B19 (CRJ-100, -200, and -440) andCL-600-2B16 (Challenger 604) airplanes. On September 28, 2005, the Safety Boardstated that, pending the FAA’s issuance of ADs that mandated correction to the Embraer145 and 135 and CRJ-100, -200, and -440 and Challenger 604 FDR systems, SafetyRecommendation A-03-15 was classified “Open—Acceptable Response.”

Since the time of the Pinnacle Airlines accident, the Safety Board has downloadedFDR data from seven events involving CL-600-2B19 airplanes—the most recent of whichoccurred on August 27, 2006.148 All of these downloads showed that the FDRs recordedthe vertical acceleration and pitch parameters from sources that did not meet the recordingintervals required by 14 CFR 121.344, Appendix M, as was the case with the FDRinstalled on the Pinnacle Airlines accident airplane.

In November 2006, Bombardier told the Safety Board that production ofChallenger 604 airplanes had ceased and that the Challenger 605 model had replaced theChallenger 604 model. Bombardier also stated that the sampling rate problem had beencorrected in the FDRs installed on Challenger 605 airplanes. However, the Board notesthat Challenger 604 airplanes that are currently in service will still have FDRs withsampling rate problems.

Bombardier further stated that, for FDRs installed on CRJ-100, -200, and -440airplanes, the sampling rate problem would be corrected during the next applicable digital

147 As stated in section 1.18.3.3, on September 28, 2005, the Safety Board stated that no problemsexisted with the FDR parameters on the Fairchild Dornier 328-300 airplane.

148 This FDR was installed aboard the Comair Airlines flight 5191 accident airplane, which crashed inLexington, Kentucky, after the pilots attempted to take off from the wrong runway. For information aboutthis accident, see DCA06MA064 at the Safety Board’s Web site at <http://www.ntsb.gov>.


control unit update, which was scheduled for the second or third quarter of 2007, and thatairplanes would be retrofitted within the 18 months that followed. Thus, if this schedulewere maintained, the sampling rate problem would not be fixed on all CL-600-2B19airplanes until late 2008 or early 2009. Also, as of December 1, 2006, the FAA had notissued an AD to correct FDR anomalies on Embraer 145 and 135 airplanes. The SafetyBoard concludes that the parameter quality problems with the FDR systems installed onCanadair CL-600-2B19, Challenger 604, and Embraer 145 and 135 airplanes need to becorrected so that future investigations involving these airplane models are not hindered byinaccurate or incomplete data. Therefore, the Safety Board reiterates SafetyRecommendation A-03-15. Further, the Board classifies Safety Recommendation A-03-15“Open—Unacceptable Response.”


3. Conclusions

3.1 Findings1. The captain and the first officer were properly certificated and qualified under Federal

regulations. No evidence indicated any medical or behavioral conditions that mighthave adversely affected their performance during the accident flight. Flight crewfatigue and hypoxia were not factors in this accident.

2. The accident airplane was properly certified, equipped, and maintained in accordancewith Federal regulations. The recovered components showed no evidence of anystructural or system failures or any engine failures before the time of the upset event.

3. Weather was not a factor in this accident.

4. The accident was not survivable.

5. The pilots’ aggressive pitch-up and yaw maneuvers during the ascent and theirdecision to operate the airplane at its maximum operating altitude (41,000 feet) weremade for personal and not operational reasons.

6. The flight crew’s inappropriate use of the vertical speed mode during the climb was amisuse of automation that allowed the airplane to reach 41,000 feet in a critically lowenergy state.

7. The improper airspeed during the climb demonstrated that the pilots did notunderstand how airspeed affects airplane performance and did not realize theimportance of conducting the climb according to the published climb capabilitycharts.

8. The upset event exposed both engines to inlet airflow disruption conditions that led toengine stalls and a complete loss of engine power.

9. The pilots’ lack of exposure to high altitude stall recovery techniques contributed totheir inappropriate flight control inputs during the upset event.

10. The captain did not take the necessary steps to ensure that the first officer achievedthe 300-knot or greater airspeed required for the windmill engine restart procedureand then did not demonstrate command authority by taking control of the airplane andaccelerating it to at least 300 knots.

Conclusions 71 Aircraft Accident Report

11. The first officer’s limited experience in the airplane might have contributed to thefailed windmill restart attempt because he might have been reluctant to command thedegree of nose-down attitude that was required to increase the airplane’s airspeed to300 knots.

12. Despite their four auxiliary power unit-assisted engine restart attempts, the pilotswere unable to restart the engines because their cores had locked. Without corerotation, recovery from the double engine failure was not possible.

13. The General Electric CF34-1 and CF34-3 engines had a history of failing to rotateduring in-flight restart attempts on airplanes undergoing production acceptancetesting at Bombardier.

14. Both engines experienced core lock because of the flameout from high power andhigh altitude, which resulted from the pilot-induced extreme conditions to which theengines were exposed, and the pilots’ failure to achieve and maintain the targetairspeed of 240 knots, which caused the engine cores to stop rotating; both of thesefactors were causal to this accident.

15. The importance of maintaining a minimum airspeed to keep the engine cores rotatingwas not communicated to the pilots in airplane flight manuals.

16. The captain’s previous difficulties in checklist management, the situational stress, andthe lack of simulator training involving a double engine failure contributed to theflight crew’s errors in performing the double engine failure checklist.

17. The pilots’ failure to prepare for an emergency landing in a timely manner, includingcommunicating with air traffic controllers immediately after the emergency about theloss of both engines and the availability of landing sites, was a result of theirintentional noncompliance with standard operating procedures, and this failure wascausal to the accident.

18. The pilots’ unprofessional operation of the flight was intentional and causal to thisaccident because the pilots’ actions led directly to the upset and their improperreaction to the resulting in-flight emergency exacerbated the situation to the point thatthey were unable to recover the airplane.

19. Revised high altitude training syllabuses for pilots who operate regional jet airplaneswould help ensure that these pilots possess a thorough understanding of the airplanes’performance capabilities, limitations, and high altitude aerodynamics.

20. Because most training for stalls occurs with the airplane at low altitudes, the trainingmethods may introduce a bias in stall recovery techniques by encouraging pilots tominimize altitude loss and not fully recognizing other available recovery techniques.


21. Additional training might improve pilot response to stickpusher activation, but suchtraining, if not provided correctly, could have an adverse impact on existing stallrecognition and recovery protocols.

22. Some of the changes made by Pinnacle Airlines to its double engine failure trainingand checklist guidance would benefit pilots at other air carriers that operate theCanadair regional jet because such training would provide pilots with the opportunityto practice double engine failure restart procedures in the simulator and the guidancewould ensure that pilots were aware of the minimum airspeeds needed during theprocedures.

23. More scrutiny of regional air carrier pilots during nonrevenue flights would minimizethe opportunity for unprofessional behavior to occur.

24. Providing additional education to pilots on the importance of professionalism couldhelp reduce the instances of pilots not maintaining cockpit discipline or not adheringto standard operating procedures.

25. Line Operations Safety Audit observations can provide operators with increasedknowledge about the behavior demonstrated by pilots during line operations.

26. All air carriers would benefit from Safety Management System programs becausethey would require the carriers to incorporate formal system safety methods into thecarriers’ internal oversight programs.

27. The establishment of an Aviation Safety Action Program and a Flight OperationalQuality Assurance program at regional air carriers would provide the carriers with ameans to evaluate the quality of their operations.

28. The parameter quality problems with the flight data recorder systems installed onCanadair CL-600-2B19, Challenger 604, and Embraer 145 and 135 airplanes need tobe corrected so that future investigations involving these airplane models are nothindered by inaccurate or incomplete data.


3.2 Probable CauseThe National Transportation Safety Board determines that the probable causes of

this accident were (1) the pilots’ unprofessional behavior, deviation from standardoperating procedures, and poor airmanship, which resulted in an in-flight emergency fromwhich they were unable to recover, in part because of the pilots’ inadequate training;(2) the pilots’ failure to prepare for an emergency landing in a timely manner, includingcommunicating with air traffic controllers immediately after the emergency about the lossof both engines and the availability of landing sites; and (3) the pilots’ impropermanagement of the double engine failure checklist, which allowed the engine cores to stoprotating and resulted in the core lock engine condition. Contributing to this accident were(1) the core lock engine condition, which prevented at least one engine from beingrestarted, and (2) the airplane flight manuals that did not communicate to pilots theimportance of maintaining a minimum airspeed to keep the engine cores rotating.


4. Safety Recommendations

4.1 New RecommendationsAs a result of the investigation of this accident, the National Transportation Safety

Board makes the following recommendations to the Federal Aviation Administration:

Work with members of the aviation industry to enhance the trainingsyllabuses for pilots conducting high altitude operations in regional jetairplanes. The syllabuses should include methods to ensure that these pilotspossess a thorough understanding of the airplanes’ performancecapabilities, limitations, and high altitude aerodynamics. (A-07-1)

Determine whether the changes to be made to the high altitude trainingsyllabuses for regional jet airplanes, as requested in SafetyRecommendation A-07-1, would also enhance the high altitude trainingsyllabuses for all other transport-category jet airplanes and, if so, requirethat these changes be incorporated into the syllabuses for those airplanes.(A-07-2)

Require that air carriers provide their pilots with opportunities to practicehigh altitude stall recovery techniques in the simulator during which timethe pilots demonstrate their ability to identify and execute the appropriaterecovery technique. (A-07-3)

Convene a multidisciplinary panel of operational, training, and humanfactors specialists to study and submit a report on methods to improveflight crew familiarity with and response to stickpusher systems and, ifwarranted, establish training requirements for stickpusher-equippedairplanes based on the findings of this panel. (A-07-4)

Verify that all Canadair regional jet operators incorporate guidance in theirdouble engine failure checklist that clearly states the airspeeds requiredduring the procedure and require the operators to provide pilots withsimulator training on executing this checklist. (A-07-5)

Require regional air carriers operating under 14 Code of FederalRegulations Part 121 to provide specific guidance on expectations forprofessional conduct to pilots who operate nonrevenue flights. (A-07-6)

Safety Recommendations 75 Aircraft Accident Report

For those regional air carriers operating under 14 Code of FederalRegulations Part 121 that have the capability to review flight data recorder(FDR) data, require that the air carriers review FDR data from nonrevenueflights to verify that the flights are being conducted according to standardoperating procedures. (A-07-7)

Work with pilot associations to develop a specific program of education forair carrier pilots that addresses professional standards and their role inensuring safety of flight. The program should include associated guidanceinformation and references to recent accidents involving pilots actingunprofessionally or not following standard operating procedures. (A-07-8)

Require that all 14 Code of Federal Regulations Part 121 operatorsincorporate into their oversight programs periodic Line Operations SafetyAudit observations and methods to address and correct findings resultingfrom these observations. (A-07-9)

Require that all 14 Code of Federal Regulations Part 121 operatorsestablish Safety Management System programs. (A-07-10)

Strongly encourage and assist all regional air carriers operating under14 Code of Federal Regulations Part 121 to implement an approvedAviation Safety Action Program and an approved Flight OperationalQuality Assurance program. (A-07-11)

4.2 Previously Issued Recommendation Reiterated and Classified in This Report

The Safety Board reiterates the following recommendation to the Federal AviationAdministration:

Require that all Embraer 145, Embraer 135, Canadair CL-600 RJ, CanadairChallenger CL-600, and Fairchild Dornier 328-300 airplanes be modifiedwith a digital flight data recorder system that meets the sampling rate,range, and accuracy requirements specified in 14 Code of FederalRegulations Part 121.344, Appendix M. (A-03-15)

Further, Safety Recommendation A-03-15 (previously classified “Open—Acceptable Response”) is classified “Open—Unacceptable Response” in section 2.5 ofthis report.

For information about this recommendation, see sections 1.18.3.3 and 2.5 of thisreport.


4.3 Previously Issued Recommendations Resulting From This Accident Investigation

As a result of the investigation into this accident, the Safety Board issued thefollowing recommendations to the Federal Aviation Administration onNovember 20, 2006:

For airplanes equipped with CF34-1 or CF34-3 engines, requiremanufacturers to perform high power, high altitude sudden engineshutdowns; determine the minimum airspeed required to maintainsufficient core rotation; and demonstrate that all methods of in-flight restartcan be accomplished when this airspeed is maintained. (A-06-70)

Ensure that airplane flight manuals of airplanes equipped with CF34-1 orCF34-3 engines clearly state the minimum airspeed required for enginecore rotation and that, if this airspeed is not maintained after a high power,high altitude sudden engine shutdown, a loss of in-flight restart capabilityas a result of core lock may occur. (A-06-71)

Require that operators of CRJ-100, -200, and -440 airplanes include inairplane flight manuals the significant performance penalties, such as lossof glide distance and increased descent rate, that can be incurred frommaintaining the minimum airspeed required for core rotation and windmillrestart attempts. (A-06-72)

Review the design of turbine-powered engines (other than the CF34-1 andCF34-3, which are addressed in Safety Recommendation A-06-70) todetermine whether they are susceptible to core lock and, for those enginesso identified, require manufacturers of airplanes equipped with theseengines to perform high power, high altitude sudden engine shutdowns anddetermine the minimum airspeed to maintain sufficient core rotation so thatall methods of in-flight restart can be accomplished. (A-06-73)

For those airplanes with engines that are found to be susceptible to corelock (other than the CF34-1 and CF34-3, which are addressed in SafetyRecommendation A-06-71), require airplane manufacturers to incorporateinformation into airplane flight manuals that clearly states the potential forcore lock; the procedures, including the minimum airspeed required, toprevent this condition from occurring after a sudden engine shutdown; andthe resulting loss of in-flight restart capability if this condition were tooccur. (A-06-74)


Require manufacturers to determine, as part of 14 Code of FederalRegulations Part 25 certification tests, if restart capability exists from acore rotation speed of 0 indicated rpm after high power, high altitudesudden engine shutdowns. For those airplanes determined to besusceptible to core lock, mitigate the hazard by providing design oroperational means to ensure restart capability. (A-06-75)

Establish certification requirements that would place upper limits on thevalue of the minimum airspeed required and the amount of altitude losspermitted for windmill restarts. (A-06-76)

For additional information about these recommendations, see section 1.18.3.1 ofthis report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARDMARK V. ROSENKERChairman

ROBERT L. SUMWALTVice Chairman

DEBORAH A. P. HERSMANMember

KATHRYN O. HIGGINSMember

STEVEN R. CHEALANDERMember

Adopted: January 9, 2007


5. Appendixes

Appendix AInvestigation and Hearing

Investigation

The National Transportation Safety Board was initially notified of this accident onOctober 14, 2004, after air traffic controllers lost contact with the airplane. A go-team wasassembled and departed for Jefferson City, Missouri, on the morning of October 15, 2004,and arrived on scene later that day. Accompanying the team to Jefferson City was formerMember Carol Carmody.

The following investigative teams were formed: Aircraft Operations, HumanPerformance, Aircraft Structures, Aircraft Systems, Powerplants, Air Traffic Control,Meteorology, Aircraft Performance, Maintenance Records, Cockpit Voice Recorder, andFlight Data Recorder. While the investigative team was in Jefferson City, specialists wereassigned to conduct the readout of the flight data recorder and transcribe the recordingfrom the cockpit voice recorder at the Safety Board’s laboratory in Washington, D.C.

Parties to the investigation were the Federal Aviation Administration (FAA),Pinnacle Airlines, the Air Line Pilots Association (ALPA), the National Air TrafficControllers Association, General Electric (GE) Engines, Honeywell, Hamilton Sunstrand,and Rockwell Collins. In accordance with the provisions of Annex 13 to the Conventionon International Civil Aviation, the Transportation Safety Board of Canada (the SafetyBoard’s counterpart agency in Canada) participated in the investigation as therepresentative of the State of Design and Manufacture. Transport Canada and BombardierAerospace participated in the investigation as technical advisors to the TransportationSafety Board of Canada, as provided in Annex 13.

Public Hearing

A public hearing was held from June 13 to 15, 2005, in Washington, D.C. MemberDeborah A.P. Hersman presided over the hearing. The issues discussed at the publichearing were aircraft and engine certification and operator and FAA oversight of flightoperations and flight crew training. Parties to the public hearing were the FAA, PinnacleAirlines, ALPA, Bombardier Aerospace, GE Engines, and Honeywell.


Appendix BCockpit Voice Recorder

The following is the transcript of the Fairchild A100S cockpit voice recorder,serial number 02804, installed on Pinnacle Airlines flight 3701, a Bombardier CL-600-2B19, N8396A, which crashed in Jefferson City, Missouri, on October 14, 2004.

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Appendix B 81 Aircraft Accident Report

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85A

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86A

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90A

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Appendix B

142A

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Appendix CPinnacle Airlines’ Double Engine Failure Checklist at the Time of the Accident

Appendix C 144 Aircraft Accident Report






Appendix DPinnacle Airlines’ Revised Double EngineFailure Checklist

REVISION 8—MAY 31, 2005 EP 1-5POWERPLANT EMERGENCIES

QUICK REFERENCE HANDBOOK

Pinnacle AirlinesNorthwest AirlinkCANADAIR REGIONAL JET

CAUTION

Failure to maintain positive N2 may preclude a suc-cessful relight. If required, increase airspeed to main-tain N2 indication.

6. Oxygen Masks (if required)................................................... DON

7. Proceed to nearest suitable airport in preparation for a possible dead-stick landing.

8. APU (below 30,000 feet) ................................................... START

9. APU GEN (if APU available) ................................................... ON

Windmilling relight possible (requires airspeed of not less than 300 KIAS):

(From 21,000 feet or below)9. Relight Using Windmilling Procedure

(See Page EP 1-6) ................................................. ACCOMPLISH

Maintain 240 KIAS until ready to initiate windmillstart.

(From 13,000 feet and below)9. Relight Using APU Bleed Air Procedure

(See Page EP 1-8)) ................................................ ACCOMPLISH

Maintain between 190 KIAS (51,000 pounds) and 170KIAS ( 36,000 pounds).

— CONTINUED —

Double Engine Failure

1. CONT IGNITION .................................................................... ON

If engines continue to run down:

2. Thrust Levers (both) .................................................... SHUT OFF

3. ADG Manual Deploy Handle............................................... PULL

When ADG power is established:

4. STAB TRIM CH 2.......................................................... ENGAGE

5. Minimum Airspeed.................................................... ESTABLISH

AIRPLANE FLIGHT LEVEL MINIMUM AIRSPEED

ABOVE FL 340 0.7 MACH

BELOW FL 340 240 KIAS

Maintain airspeed until ready to restart engines.

NO

YES?

Appendix D 150 Aircraft Accident Report

EP 1-6 REVISION 8—MAY 31, 2005

POWERPLANT EMERGENCIES


Pinnacle Airlines Northwest AirlinkCANADAIR REGIONAL JET

NOTENOTEAn altitude loss of approximately 5,000 feet can beexpected when accelerating from 240 to 300 KIASand may require pitch attitudes of 10° nose down. Ifpossible, crews should start accelerating to achieve300 KIAS upon reaching 21,000 feet.

Attempt to start both engines at the same time:1. Airspeed................ ACCELERATE TO 300 KIAS OR GREATER

CAUTION

300 KIAS or greater is required to achieve sufficient N2for start. Airspeed must be maintained until at least oneengine relights (stable idle) or start attempts abandoned.

At 21,000 feet and below:2. CONT IGNITION ................................................. CONFIRM ON 3. L and R FUEL BOOST

PUMP Switches..................................................... CONFIRM ON

When ITT is 90°C or less and N2 is:

● At least 12% (above 15,000 feet) or

● At least 9% (15,000 feet and below):4. Thrust Levers (both) .............................................................. IDLE 5. Engine Indications ....................................................... MONITOR

At least one engine relights within 25 seconds:

1. Thrust Lever(s) .................................................... AS REQUIRED

2. Affected GEN............................................................. CHECK ON

Operative engine:3. L AND/OR R 10th STAGE BLEED(s) ................. CHECK OPEN

4. Applicable PACK(s) ................................................... CHECK ON

Reestablish normal power:5. ADG Manual Deploy Handle.............................................. STOW

6. ADG PWR TXFR....................................................... OVERRIDE

7. Single Engine Procedures(See Page AP 1-2)................................................. ACCOMPLISH

IF REQUIRED—END—

6. Thrust Levers................................................................ SHUTOFF

— CONTINUED —

Double Engine Failure (Cont)

Relight using windmilling:

NO

YES?


AUGUST 1, 2002 EP 1-7POWERPLANT EMERGENCIES



Another windmilling relight attempt still possible:

7. Airspeed ............................................................ 300 TO 335 KIAS

8. Wait 30 seconds, then repeat relight procedure.

7. Relight using APU bleed air.

— CONTINUED —


Relight using windmilling:

NO

YES?


EP 1-8 REVISION 8—MAY 31, 2005

POWERPLANT EMERGENCIES


Pinnacle Airlines Northwest AirlinkCANADAIR REGIONAL JET

From 13,000 feet and below:1. Target airspeed...................................................... REESTABLISH

AIRPLANE WEIGHT TARGET BEST GLIDE SPEED51,000 lb 190 KIAS36,000 lb 170 KIAS

2. CONT IGNITION ................................................. CONFIRM ON

3. L and R FUEL BOOST PUMP Switches............. CONFIRM ON

4. ANTI-ICE, WING and COWL Switches ....................... ALL OFF

5. L and R 10th STAGE BLEED Switches ......... SELECT CLOSED

6. APU LCV Switch ................................................. SELECT OPEN

Attempt to start one engine at a time:7. L or R ENG START ............................................................. PUSH

When N2 is 28% or greater and ITT is 90°C or less:8. Thrust Lever .......................................................................... IDLE

9. Engine Indications ....................................................... MONITOR

Engine relights (within 25 seconds):

1. Thrust Lever ......................................................... AS REQUIRED

2. Operative GEN .......................................................... CHECK ON

Operative engine:3. Applicable 10TH STAGE BLEED........................ CHECK OPEN

4. Applicable PACK ....................................................... CHECK ON

Reestablish normal power:5. ADG Manual Deploy Handle.............................................. STOW

6. ADG PWR TXFR....................................................... OVERRIDE

7. Single Engine Procedures(See Page AP 1-2)................................................. ACCOMPLISH

— END —

8. Affected Engine, Thrust Lever ..................................... SHUTOFF

9. Affected ENG STOP ............................................................ PUSH

10. Attempt relight on other engine.

— CONTINUED —


Relight usingAPU bleed air:

NO

Neither engine is restarted:

YES?


REVISION 8—MAY 31, 2005 EP 1-9POWERPLANT EMERGENCIES



1. Consider a forced landing or ditching. Notify cabin crew.

2. Thrust Levers (both) ..................................................... SHUTOFF

3. Target airspeed ..................................................... REESTABLISH

AIRPLANE WEIGHT TARGET BEST GLIDE SPEED

51,000 lb 190 KIAS36,000 lb 170 KIAS

4. Prepare for a forced landing or ditching (See Page EP 7-2).

— — — END — — —


Neither engine is restarted:


Appendix ECore Lock Safety Recommendation Letter

E

PLURIBUS UNUM

NA

TIO

NA

LTRA S PO

RT

AT

ION

B OARD

SA

FE T Y

N National Transportation Safety Board Washington, D.C. 20594

Safety Recommendation

Date: November 20, 2006

In reply refer to: A-06-70 through -76

Honorable Marion C. Blakey

Administrator

Federal Aviation Administration

Washington, DC 20591

On October 14, 2004, Pinnacle Airlines flight 3701 (doing business as Northwest

Airlink), N8396A, a Bombardier CL-600-2B191 equipped with General Electric (GE) CF34-3

turbofan engines, crashed into a residential area about 2.5 miles south of Jefferson City

Memorial Airport (JEF), Jefferson City, Missouri. The airplane was on a repositioning flight2

from Little Rock National Airport, Little Rock, Arkansas, to Minneapolis-St. Paul International

Airport, Minneapolis, Minnesota. The captain and the first officer were killed, and the airplane

was destroyed. No one on the ground was injured. The flight was operating under the provisions

of 14 Code of Federal Regulations (CFR) Part 91 on an instrument flight rules flight plan. Visual

meteorological conditions prevailed at the time of the accident.

The accident flight crew decided to climb to the airplane’s maximum operating altitude of

41,000 feet.3 The airplane arrived at 41,000 feet at less than its best rate of climb speed and

slowed to its stall speed. An aerodynamic stall followed, which resulted in a loss of control of

the airplane. The flight data recorder (FDR) and the cockpit voice recorder (CVR) indicated that

the engines were operating normally before the upset. The flight crew recovered the airplane

from the upset at an altitude of 34,000 feet. However, during the upset, the airflow to the engine

inlets was disrupted, and both engines flamed out.4 The rotation speed of both engines’ cores

(N2) continued to decrease.5 Before the airplane descended to an altitude of 28,000 feet, the core

1 The accident airplane was a Canadair regional jet (CRJ) -200 model, which is one of three models in the CL-600-2B19 series. (The other two models are the CRJ-100 and CRJ-440.) Bombardier acquired Canadair in December 1986.

2 A repositioning flight relocates an airplane to the airport where the airplane’s next flight is scheduled. Repositioning flights do not carry passengers or cargo.

3 A maximum operating altitude is the maximum density altitude at which the best rate of climb airspeed will produce a 100-feet-per-minute (fpm) climb at maximum weight, while in a clean configuration, and with maximum continuous power. For the CRJ-200, the maximum operating altitude represents the maximum capability of the airplane; the actual climb capability will primarily depend on airspeed, weight, and ambient temperature. The accident airplane was not at maximum weight and was capable of climbing at a rate greater than 100 fpm while at an altitude of 41,000 feet if the airspeed had been maintained at Mach 0.7 during the climb and at altitude.

4 A flameout is an interruption of a turbine engine’s combustion process that results in an uncommanded engine shutdown.

5 A turbine engine gas generator section is commonly referred to as the core.

7695A

Appendix E 155 Aircraft Accident Report

2

rotation speed of both engines had reached 0 indicated rpm. The flight crew attempted to restart

the engines several times but was unable to do so. The flight crew then attempted to make an

emergency landing at JEF, but the airplane crashed before reaching the airport.6

This accident is still under investigation, and the National Transportation Safety Board

has not yet determined the probable cause of the accident. Nonetheless, the investigation has

revealed a safety issue regarding a condition that can preclude pilots from restarting an engine

after a double engine failure.

Restart Attempts for Accident Engines

Pinnacle Airlines’ double engine failure checklist at the time of the accident indicated that

pilots were to maintain a target airspeed of 240 knots.7 The purpose of maintaining this airspeed

was to keep the engine cores rotating at an appropriate speed for either a windmill restart8 or an

auxiliary power unit (APU)-assisted restart.9 FDR data and the CVR recording showed that the

flight crew did not accelerate the airplane after the upset and that the engine core rotation slowed

to 0 indicated rpm. FDR data also showed that the crew did not achieve the 240-knot airspeed

before or after attempting to restart the engines.

The flight crew first attempted to restart the engines using the windmill restart procedure.

A windmill restart requires accelerating the airplane to an airspeed of at least 300 knots to

increase the core rotation speed before the attempted restart. FDR data showed that the crew did

not achieve the 300-knot airspeed (the maximum airspeed recorded by the FDR was 236 knots)

and that the engine cores remained at 0 indicated rpm during the restart attempt. The CVR

recording indicated that the flight crewmembers then elected to descend to an altitude of

13,000 feet so that they could attempt to restart the engines using the APU-assisted restart

procedure, which requires slowing the airplane to 170 or 190 knots (depending on the airplane’s

weight) before initiating the restart. Once the airplane descended to an altitude of 13,000 feet,

the flight crew attempted four APU-assisted engine restarts (two attempts per engine), but FDR

data showed that the engine cores still remained at 0 indicated rpm.

The accident airplane’s APU and start system components were found mostly intact at the

accident scene. Examination and testing of these components found nothing that would have

prevented adequate torque from being delivered to the engines for the restart attempts. Engine

disassembly inspections found no mechanical failures or evidence of any condition that would

have prevented engine core rotation. Although the inspections disclosed thermal damage in the

No. 2 engine that would have impeded the engine’s ability to produce thrust, this damage would

not have prevented core rotation during an attempted restart.10

6 For more information about this accident, see DCA05MA003 at the Safety Board’s Web site at <http://www.ntsb.gov>.

7 All airspeeds cited in this letter are knots indicated airspeed. 8 A windmill restart is an emergency in-flight procedure in which the effect of ram airflow passing through

the engine as the airplane moves through the air provides rotational energy to turn the core. 9 Pinnacle Airlines’ double engine failure checklist indicated that the windmill restart procedure was to be

used at altitudes from 21,000 to 13,000 feet and that the APU-assisted restart procedure was to be used at altitudes of 13,000 feet and below.

10 The inspections found no preimpact damage to the No. 1 engine.


3

Manufacturer’s Core Lock Screening Procedure

During the accident investigation, the Safety Board learned that GE CF34-1 and CF34-3

engines11

had a history of failing to rotate during in-flight restart attempts on airplanes

undergoing production acceptance flight testing at Bombardier. The manufacturers referred to

this condition as “core lock.” Bombardier first identified this problem in 1983 during Challenger

certification tests, and GE attributed the problem to interference contact at a high pressure

turbine (HPT) air seal.

The CF34 HPT air seals are designed to control cooling and balance airflow. The seals

include teeth on the rotating components that grind operating grooves into abradable surfaces on

the stationary components. The efficiency of these seals significantly affects engine

performance, so the seals are designed to operate with minimal clearances.

Bombardier added a procedure to the production acceptance flight tests for its CF34-1- and

CF34-3-powered airplanes to screen engines for the potential to experience core lock. At the time

of the accident, this screening procedure was as follows:

1. Climb to flight level 310.

2. Retard the test engine throttle to idle and stabilize for 5 minutes.

3. Shut down the test engine.

4. Descend at 190 knots.

5. Slow the aircraft until N2 is reduced to 0 percent.

6. At 8 1/2 minutes from shutdown, push over to 320 knots.

7. If N2 is 0 rpm at flight level 210, the engine is declared to be core locked.

Engines that are found to be core locked are reworked using an in-flight “grind-in”

procedure that was designed to remove seal material at the interference location.12

Engines that

undergo grind-in rework are then rescreened for core lock. The grind-in procedure, which

includes a cross-bleed start for the core locked engine, is as follows:

1. Air turbine starter cross-bleed start.

2. Ascend to flight level 310.

3. Repeat core lock screening procedure but descend at an airspeed of about 240 knots

to establish 4 percent N2.

4. Maintain 4 percent N2 for at least 8 1/2 minutes.

5. Confirm that no core lock exists by repeating screening procedure.

As testimony during the Safety Board’s June 2005 public hearing on the Pinnacle Airlines

accident indicated, neither Bombardier nor GE considered core lock to be a safety-of-flight issue.

The manufacturers claimed that engines that passed the screening procedure, with or without

grind-in rework, would not core lock as long as the 240-knot airspeed was maintained.

11 Bombardier airplanes that are powered by either GE CF34-1 or CF34-3 engine models are the Challenger 601, Challenger 604, CRJ-100, CRJ-200, and CRJ-440.

12 Newly manufactured engines undergo a test cell seal grind-in before delivery.


4

Turbine Engine Shutdowns

The operating temperatures in parts of the HPT reach more than 2,000 Fahrenheit. After

a turbine engine has been operating, its rotating and stationary components have expanded to

their normal operating dimensions and clearances. When an engine is shut down, its rotating and

stationary components do not contract at the same rates because of differences in their material

properties and their exposure to cooling air. Temporary losses of clearance between the rotating

and stationary components and misalignment between the rotating teeth and stationary grooves

of the air seal occur until the temperatures of the components reach equilibrium. Because of this

characteristic, turbine engine shutdown procedures include operation for several minutes at a

lower power setting to permit internal temperatures and clearances to stabilize. Engines that

flame out suddenly in flight experience more severe thermal changes that may result in losses of

clearance so that the rotating and stationary components rub or bind.

More importantly, flameouts at high power and high altitude conditions produce even

greater thermal distress because internal temperatures are the hottest at high power settings and

the air is colder at high altitudes. The increased thermal shock exacerbates the loss of component

clearance and alignment. Because the accident engines flamed out under these conditions, axial

misalignment caused the seal teeth, which were positioned aft of their normal grooves, to contact

stationary abradable material when radial seal clearances closed down. Once core rotation

stopped, binding prevented core rotation from resuming during the windmill or APU-assisted

restart attempts. Thus, the lack of core rotation on the accident airplane engines could be

explained by the core lock phenomenon.

Potential for Core Lock in CF34-1 and CF34-3 Engines

Bombardier’s core lock screening procedure requires a cool-down period before engine

shutdown to stabilize internal temperatures and clearances.13

However, as previously discussed,

this procedure does not produce the more severe thermal distress associated with the high power,

high altitude flameouts that occurred during the accident flight. Thus, the successful

demonstration of Bombardier’s production flight test procedure may not ensure that an engine

will not experience core lock if the core is allowed to stop rotating after a high power, high

altitude flameout. In fact, the Safety Board notes that the No. 1 accident engine had successfully

passed the screening procedure during initial production acceptance testing.14

Also, the

successful demonstration of Bombardier’s production flight test procedure may not ensure that

slowing the airplane to an airspeed of 170 to 190 knots is sufficient to maintain core rotation

during an attempted APU-assisted restart.

During the public hearing for the Pinnacle Airlines accident, a GE manager testified,

“As long as core rotation is maintained, you will not have core lock … we have a body of data

13 After the accident, Transport Canada mandated that Bombardier change the engine stabilization time from 5 to 2 minutes.

14 The No. 2 accident engine was installed new as a spare engine and was not subject to the the core lock screening procedure because it applies only to engines that are installed in Bombardier’s production airplanes.


5

that shows that 240 knots maintains core rotation.”15

This testimony suggests that the most

effective way to mitigate the safety risk of core lock during in-flight restarts is to use an

operational procedure to keep an engine’s core rotating until a restart can be attempted. The

Safety Board is unaware of flight test data that demonstrate that 240 knots is sufficient to keep

the core rotating after the more severe thermal distress associated with a high power, high

altitude flameout. Thus, the Board is concerned that sufficient testing and engineering analysis

have not been performed to demonstrate whether the 240-knot airspeed is effective in

maintaining core rotation and preventing core lock after high power, high altitude flameouts.

The Safety Board concludes that it is critical to identify the airspeed needed to maintain

core rotation in CF34-1 and CF34-3 engines after high power, high altitude flameouts and to

ensure that restart procedures can be accomplished under such conditions. Therefore, the Safety

Board believes that, for airplanes equipped with CF34-1 or CF34-3 engines, the Federal Aviation

Administration (FAA) should require manufacturers to perform high power, high altitude sudden

engine shutdowns; determine the minimum airspeed required to maintain sufficient core rotation;

and demonstrate that all methods of in-flight restart can be accomplished when this airspeed is

maintained.16

The importance of maintaining a minimum airspeed to keep the engine cores rotating was

not communicated to pilots in airplane flight manuals (AFM). For example, at the time of the

accident, Bombardier’s and Pinnacle Airlines’ double engine failure checklists stated that

240 knots was the “target” airspeed for the procedure but did not indicate that this airspeed was

essential to the success of the restart procedure. As a result of the accident, Bombardier and

Pinnacle Airlines revised their double engine failure checklists to indicate that 240 knots was the

“minimum” airspeed and that the failure to maintain positive core rotation might prevent a

successful restart.

The Safety Board concludes that it is important for pilots to be aware of the possibility of

core lock and the specific actions that are needed to preclude this condition. Therefore, the

Safety Board believes that the FAA should ensure that AFMs of airplanes equipped with CF34-1

or CF34-3 engines clearly state the minimum airspeed required for engine core rotation and that,

if this airspeed is not maintained after a high power, high altitude sudden engine shutdown, a loss

of in-flight restart capability as a result of core lock may occur.

Performance Penalties for CRJ-100, -200 and -440 Airplanes

The 240-knot airspeed included in Bombardier’s and Pinnacle Airlines’ double engine

failure checklists is 70 knots greater than the airplane’s best glide speed17

(at an airplane weight

of 36,000 pounds) of 170 knots. To maintain the 240-knot airspeed with no engine power and

15 The GE manager further testified that the 240-knot airspeed also served to maintain a minimal hydraulic pressure.

16 The Safety Board notes that Bombardier Aerospace and Transport Canada have performed high altitude, high power engine shutdowns to verify the 240-knot target airspeed included in Bombardier’s double engine failure checklist. The APU-assisted in-flight restart process has not yet been verified.

17 An airplane’s best glide speed provides the airplane with the most distance forward for a given loss of altitude.


6

transition to a 300-knot airspeed for a windmill restart, a flight crew must significantly increase

the airplane’s descent rate, thereby reducing the range of available landing locations if a forced

(emergency) landing were to become necessary as a result of a failure to restart at least one

engine. Because of the effect that this loss of glide range could have on a flight crew’s ability to

find a viable emergency landing site, the Safety Board concludes that CRJ-100, -200, and -440

pilots must be fully aware of the performance penalties that can be incurred while maintaining

core rotation and attempting a windmill restart. Therefore, the Safety Board believes that the

FAA should require that operators of CRJ-100, -200, and -440 airplanes include in AFMs the

significant performance penalties, such as loss of glide distance and increased descent rate, that

can be incurred from maintaining the minimum airspeed required for core rotation and windmill

restart attempts.

Potential for Core Lock in Other Engine Models

Turbine-powered airplanes other than the Challenger 601 and 604 and the CRJ-100, -200,

and -440 have turbine engine components with a similar physical design as those for the CF34-1

and CF34-3 engines. As a result, the Safety Board concludes that other turbine engines may also

be susceptible to core lock after high power, high altitude flameouts. Therefore, the Safety

Board believes that the FAA should review the design of turbine-powered engines (other than the

CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-70) to determine

whether they are susceptible to core lock and, for those engines so identified, require

manufacturers of airplanes equipped with these engines to perform high power, high altitude

sudden engine shutdowns and determine the minimum airspeed to maintain sufficient core

rotation so that all methods of in-flight restart can be accomplished. Further, the Safety Board

believes that, for those airplanes with engines that are found to be susceptible to core lock (other

than the CF34-1 and CF34-3, which are addressed in Safety Recommendation A-06-71), the

FAA should require airplane manufacturers to incorporate information into AFMs that clearly

states the potential for core lock; the procedures, including the minimum airspeed required, to

prevent this condition from occurring after a sudden engine shutdown; and the resulting loss of

in-flight restart capability if this condition were to occur. In addition, the Safety Board believes

that the FAA should require manufacturers to determine, as part of 14 CFR Part 25 certification

tests, if restart capability exists from a core rotation speed of 0 indicated rpm after high power,

high altitude sudden engine shutdowns. For those airplanes determined to be susceptible to core

lock, the FAA should mitigate the hazard by providing design or operational means to ensure

restart capability.

Windmill Restart Requirements

Airplane manufacturers rely on the windmill method as the primary means of restart after

an all-engine flameout event. Consequently, the portion of the flight envelope in which a

windmill restart is effective is critical to flight safety. However, increases in the bypass ratios of

turbofan engines over the years have significantly reduced the windmill restart portion of the

in-flight restart envelope. Specifically, the engines powering many current transport-category

airplanes bypass between 80 and 90 percent of the airflow entering the inlet around the engine

core, so as little as 10 percent of the inlet air enters the core during normal operation. Thus, the


7

cores of high bypass ratio engines, such as the CF34,18

require significantly higher airspeeds to

achieve windmill restart than the cores of low bypass engines installed on older generation

airplanes.

After an all-engine high power flameout, pilots need to sacrifice a substantial amount of

altitude to achieve the higher airspeeds that are necessary for a windmill restart with high bypass

engines. However, depending on the altitude where the shutdown occurred, a pilot may not have

enough altitude available to use this restart option.

Certification requirements currently address the minimum airspeed needed to ensure

windmill restart capability. However, there is no upper limit on the value of the minimum

airspeed required for a windmill restart and no limit on the amount of altitude loss that can occur

during a windmill restart. If the minimum airspeed value is too high, an excessive amount of

altitude loss may be needed to accomplish a windmill restart. In September 1999, the FAA

issued a notice of availability and request for comments on a proposed Propulsion Mega

Advisory Circular,19

which addressed this and other engine certification-related issues, but the

FAA has taken no subsequent action.

The Safety Board concludes that, during design, airplane manufacturers must consider

that a pilot’s ability to restart high bypass turbine engines after an all-engine flameout might be

compromised if an excessive airspeed or an excessive amount of altitude loss were needed for

the restart. Therefore, the Safety Board believes that the FAA should establish certification

requirements that would place upper limits on the value of the minimum airspeed required and

the amount of altitude loss permitted for windmill restarts.

Therefore, the National Transportation Safety Board recommends that the Federal

Aviation Administration:

For airplanes equipped with CF34-1 or CF34-3 engines, require manufacturers to

perform high power, high altitude sudden engine shutdowns; determine the

minimum airspeed required to maintain sufficient core rotation; and demonstrate

that all methods of in-flight restart can be accomplished when this airspeed is

maintained. (A-06-70)

Ensure that airplane flight manuals of airplanes equipped with CF34-1 or CF34-3

engines clearly state the minimum airspeed required for engine core rotation and

that, if this airspeed is not maintained after a high power, high altitude sudden

engine shutdown, a loss of in-flight restart capability as a result of core lock may

occur. (A-06-71)

Require that operators of CRJ-100, -200, and -440 airplanes include in airplane

flight manuals the significant performance penalties, such as loss of glide distance

and increased descent rate, that can be incurred from maintaining the minimum

airspeed required for core rotation and windmill restart attempts. (A-06-72)

18 The CF34 engine bypasses about 85 percent of inlet air past the core. 19 For more information, see 64 Federal Register 52819, September 30, 1999.


8

Review the design of turbine-powered engines (other than the CF34-1 and

CF34-3, which are addressed in Safety Recommendation A-06-70) to determine

whether they are susceptible to core lock and, for those engines so identified,

require manufacturers of airplanes equipped with these engines to perform high

power, high altitude sudden engine shutdowns and determine the minimum

airspeed to maintain sufficient core rotation so that all methods of in-flight restart

can be accomplished. (A-06-73)

For those airplanes with engines that are found to be susceptible to core lock

(other than the CF34-1 and CF34-3, which are addressed in Safety

Recommendation A-06-71), require airplane manufacturers to incorporate

information into airplane flight manuals that clearly states the potential for core

lock; the procedures, including the minimum airspeed required, to prevent this

condition from occurring after a sudden engine shutdown; and the resulting loss

of in-flight restart capability if this condition were to occur. (A-06-74)

Require manufacturers to determine, as part of 14 Code of Federal Regulations

Part 25 certification tests, if restart capability exists from a core rotation speed of

0 indicated rpm after high power, high altitude sudden engine shutdowns. For

those airplanes determined to be susceptible to core lock, mitigate the hazard by

providing design or operational means to ensure restart capability. (A-06-75)

Establish certification requirements that would place upper limits on the value of

the minimum airspeed required and the amount of altitude loss permitted for

windmill restarts. (A-06-76)

Chairman ROSENKER, Vice Chairman SUMWALT, and Members HERSMAN and

HIGGINS concurred with these recommendations.

[Original Signed]

By: Mark V. Rosenker

Chairman

Documents

Crash of Pinnacle Airlines Flight 3701 Bombardier CL-600 ...libraryonline.erau.edu/online-full-text/ntsb/aircraft-accident-reports/AAR07-01.pdf · Crash of Pinnacle Airlines Flight